Diagnosis typing, prefixes and clusters

The problem deemed the clinically significant reason for the visit, requiring evaluation, treatment or management, and assigned by the health care provider at the end of the visit. Where several problems compete, the one responsible for the greatest use of resources. For a patient who left without being seen, the presenting complaint.

Main and Other Problem Definitions for NACRS

Mandatory where the condition or circumstance exists at the time of the visit and is significant to treatment or care - that is, it requires monitoring and/or treatment - or where another standard or the classification itself directs it. Optional otherwise.

Optional capture is only reliable when mandated jurisdiction-wide or facility-wide; ad hoc assignment by individual coders is not valid for use.

Coding of Main and Other Problems for NACRS

Dagger and asterisk

An aetiology code (dagger) sequenced before the manifestation code (asterisk) it gives rise to. The asterisk code can never stand alone as a primary diagnosis.

Dagger/Asterisk Convention

Injury with external cause

An injury, poisoning or adverse effect clustered with the external cause code that produced it, and with a place-of-occurrence code where the jurisdiction requires one.

External Cause Codes

Device or procedural complication

A complication of an internal device, implant or graft clustered with the external cause code identifying the procedure that placed it. A post-implant problem is not coded to a primary disease of the joint or organ.

Diagnosis Cluster

Underlying condition with manifestation

A systemic condition clustered with the organ-specific manifestation it produced, so downstream analysis does not read them as unrelated.

Diagnosis Cluster