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ResiCAT User Manual
Version 1.4 86
7 DEFINITIONS
7.1 CLASSIFICATION OF CODING CHANGES – ERROR TYPE
Incorrect principal diagnosis
This category is assigned if the selection of the principal diagnosis is incorrect. It is applied
where the code itself is correct but has not been placed as the first (principal) diagnosis and
would not be assigned where the condition selected as principal diagnosis is correct but the
actual code is incorrect (e.g. diarrhoea is principal diagnosis but wrong code for diarrhoea has
been selected). In the latter case, the discrepancy would be classified as 'Incorrect diagnosis
code'.
Incorrect diagnosis code
Used where the code selected for a diagnosis code is incorrect at any level.
Missing additional diagnosis code
Used where a secondary diagnosis code is not recorded but is justified by the documentation and
meets the Australian Coding Standard for an additional diagnosis.
Unjustified diagnosis code (unnecessary or unsubstantiated)
Used where a condition that has no bearing on the care or treatment of the patient during the
episode of care has been coded or the use of a diagnosis code without sufficient information in
the record to substantiate its use. This category includes codes where either the base condition
or the 5th digit level is not substantiated by clinical documentation.
Incorrect procedure code
Any occasion within an admission where the procedure code was incorrect at any level.
Missing procedure code
Used where a procedure code was not recorded but was justified by the documentation.
Unjustified procedure code (unnecessary or unsubstantiated)
Coding of a procedure that is not required to be coded or the use of a procedure code without
sufficient information in the record to substantiate its use.
Other
A discrepancy that does not fit into any of the categories above.