What is the first step in an inpatient record review?

The first step in an inpatient record review is to verify the correct assignment of the principal diagnosis. This step is critical because the principal diagnosis serves as the foundation for the entire coding process. Accurately determining the principal diagnosis ensures that the subsequent coding for procedures and ancillary diagnoses are correctly aligned, reflecting the patient's primary reason for admission.

A correct principal diagnosis is vital for various reasons, including determining the appropriate reimbursement from payers, ensuring compliance with regulations, and providing data for quality monitoring and improvement. If the principal diagnosis is misidentified, it may lead to incorrect coding, which can result in claims denials and inadequate reimbursement.

Thus, confirming the accuracy of the principal diagnosis before moving on to assigning codes for procedures or evaluating billing statements is essential, making this the logical first step in the inpatient record review process.