--- title: Sequencing of the Principal Procedure description: The procedure that is performed for definitive treatment or is taking care of a complication is the principal procedure. image: https://hiacode.com/hubfs/Imported_Blog_Media/iStock-506138196-1.jpg --- # Sequencing of the Principal Procedure ![HIAcode](https://hiacode.com/hubfs/Logos/HIA_RGB_PrimaryLogo_Icon%20(1)_Artboard%201.png) [HIAcode](https://hiacode.com/blog/author/hiacode) Aug 13, 2022 [Industry News](https://hiacode.com/blog/tag/industry-news) [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) ![Sequencing of the Principal Procedure](https://hiacode.com/hubfs/Imported_Blog_Media/iStock-506138196-1.jpg) - Share on: - [![](https://hiacode.com/hubfs/Facebook%20svg.svg)](http://www.facebook.com/share.php?u=https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure) - [![](https://hiacode.com/hs-fs/hubfs/twitter.png?width=32&height=32&name=twitter.png)](https://twitter.com/intent/tweet?text=I+found+this+interesting+blog+post&url=https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure) - [![](https://hiacode.com/hubfs/LinkedIn%20svg.svg)](http://www.linkedin.com/shareArticle?mini=true&url=https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure) - [![](https://hiacode.com/hubfs/mdi_email.svg)](mailto:?subject=Check%20out%20https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure%20&body=Check%20out%20https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure&media=https://20824215.fs1.hubspotusercontent-na1.net/hubfs/20824215/Imported_Blog_Media/iStock-506138196-1.jpg) - ![](https://hiacode.com/hubfs/entypo_link.svg) copied During reviews we notice there is often confusion amongst coders as to what procedure should be listed first. Here is some information on the principal procedure that will help coders know which procedure is considered the principal procedure and should be reported first. Some think it is the “most complex” procedure, but that is not always the case. Coders will sometimes put the procedures in chronological order, but that is not always correct.   ## What is the principal procedure? The procedure that is performed for definitive treatment or is taking care of a complication is the principal procedure. Procedures for diagnostic or exploratory purposes that are performed in addition to a procedure being performed for definitive treatment, would be reported in addition to the principal procedure. An example of definitive and diagnostic procedures being performed on the same admission would be: Patient is admitted with chest pain and this is worked up with cardiac catheterization/angiography. The patient is found to have significant coronary artery disease and is then scheduled for bypass surgery on the same date. In this case, the coronary artery bypass is the principal procedure as it is being performed for definitive treatment of the heart disease. The heart catheterization and angiography would be reported as additional procedures since they were diagnostic tests. Sometimes, there are only diagnostic/exploratory procedures performed. If this is the case, then one of these would be reported first. In the example above the MS-DRG would be the same regardless of the sequencing, HOWEVER for consistency and accuracy in reporting data the coding guidelines should be followed. **ICD-10-PCS Official Guidelines for Coding and Reporting 2023 Page 20:** ***Selection of Principal Procedure*** The following instructions should be applied in the selection of principal procedure and clarification on the importance of the relation to the principal diagnosis when more than one procedure is performed: 1. Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure. 1. Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis. a. Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure 1. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis. a. Sequence diagnostic procedure as principal procedure since the procedure most related to the principal diagnosis takes precedence. 1. No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis a. Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis. ## Additional Examples: - Patient is admitted with respiratory failure and acute MI placed on mechanical ventilation. He also had PTCA with stent of the coronary artery. The principal procedure would be the PTCA/stent and not the mechanical ventilation. The PTCA/stent is considered definitive treatment and directed towards the PDX. - Patient is admitted with GI bleeding and underwent colonoscopy to look for the etiology of the bleeding. The patient is found to have a bleeding sigmoid polyp that is biopsied and found to be positive for adenocarcinoma. The patient (during this same admission) is taken to surgery and resection of the sigmoid colon was performed. The principal procedure would be the sigmoid resection as this is the procedure that was completed for definitive treatment. The colonoscopy and biopsy would be reported as an additional procedure. - Patient is admitted with acute CVA and this is found to be due to carotid artery occlusion. The patient is taken to surgery for endarterectomy of the carotid artery. The day following the procedure the patient is found to have suffered an acute MI after the surgery. The patient is worked up for this and coronary bypass was recommended. On this same admission, the patient does have coronary bypass. The principal procedure would be the carotid endarterectomy as this is the definitive procedure that is related to the principal diagnosis. *Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P* *References ICD-10-PCS Official Guidelines for Coding and Reporting 2022 Page: 19 AHA Coding Clinic®, Fourth Quarter 1990 Page: 5 to 6 AHA Coding Clinic®, Second Quarter 2011 Page: 3* --- [HIA’s comprehensive auditing approach](https://hiacode.com/acute-review-services) includes [acute coding audits](https://hiacode.com/acute-review) and [Clinical Documentation Integrity (CDI) audits](https://hiacode.com/clinical-documentation-integrity). ---   [![Principal Primary ICD-10-PCS Procedure Selection ](https://no-cache.hubspot.com/cta/default/20824215/159096c8-7eab-46e9-ad78-9c7c781ed8b4.png)](https://cta-redirect.hubspot.com/cta/redirect/20824215/159096c8-7eab-46e9-ad78-9c7c781ed8b4) > ***The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.*** ##### [Previous](https://hiacode.com/blog/education/type-2-nstemi-reporting) ### [Type 2 NSTEMI Reporting](https://hiacode.com/blog/education/type-2-nstemi-reporting) ##### [Next](https://hiacode.com/blog/education/coding-tip-obstetric-tidbits-for-pcs) ### [Obstetric Tidbits for PCS](https://hiacode.com/blog/education/coding-tip-obstetric-tidbits-for-pcs) Serach Blog Post ## Need to Earn CEUs? Our coding education platform, HIAlearn.com, offers courses related to this topic and many more. Subscribe today and access more than 230 courses accepted by AHIMA for CEUs, with a selection also accepted by AAPC. ![CTA Sidebar HIAlearn logo-1](https://hiacode.com/hs-fs/hubfs/CTA%20Sidebar%20HIAlearn%20logo-1.png?width=1080&height=189&name=CTA%20Sidebar%20HIAlearn%20logo-1.png) [![Learn More](https://no-cache.hubspot.com/cta/default/20824215/f611164b-1c02-4b86-a2aa-6033633d4569.png)](https://cta-redirect.hubspot.com/cta/redirect/20824215/f611164b-1c02-4b86-a2aa-6033633d4569) #### Category - [Medical Coding Tips (371)](https://hiacode.com/blog/tag/medical-coding-tips) - [Industry News (340)](https://hiacode.com/blog/tag/industry-news) - [Company News (23)](https://hiacode.com/blog/tag/company-news) - [Query Tips (23)](https://hiacode.com/blog/tag/query-tips) - [Annual Code Updates (16)](https://hiacode.com/blog/tag/annual-code-updates) - [CDI Tips (9)](https://hiacode.com/blog/tag/cdi-tips) ### Subscribe to our Newsletter #### Recent Blogs Jul 08, 2026 [Industry News](https://hiacode.com/blog/tag/industry-news) [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) ### [Central Venous Access Devices ...](https://hiacode.com/blog/central-venous-access-devices) Jul 01, 2026 [Industry News](https://hiacode.com/blog/tag/industry-news) [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) ### [ICD-10-CM Coding for Colonosco...](https://hiacode.com/blog/icd-10-cm-coding-for-colonoscopy-following-positive-cologuard-result) Jun 24, 2026 [Industry News](https://hiacode.com/blog/tag/industry-news) [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) ### [20,000 Inpatient Reviews Revea...](https://hiacode.com/blog/20k-inpatient-coding-reviews-principal-diagnosis-pcs-revenue-integrity) Jun 10, 2026 [Industry News](https://hiacode.com/blog/tag/industry-news) [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) ### [Big Changes Coming to CPT Codi...](https://hiacode.com/blog/big-changes-coming-to-cpt-coding-for-maternity-care) ## Related blogs from Industry News , Medical Coding Tips Jul 08, 2026 [Industry News](https://hiacode.com/blog/tag/industry-news),  [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) #### [Central Venous Access Devices - An Overview](https://hiacode.com/blog/central-venous-access-devices) Accurate ICD-10-PCS and CPT coding for proced... [ Read More](https://hiacode.com/blog/central-venous-access-devices) Jul 01, 2026 [Industry News](https://hiacode.com/blog/tag/industry-news),  [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) #### [ICD-10-CM Coding for Colonoscopy Following Positiv...](https://hiacode.com/blog/icd-10-cm-coding-for-colonoscopy-following-positive-cologuard-result) A colonoscopy prompted by a positive Cologuar... [ Read More](https://hiacode.com/blog/icd-10-cm-coding-for-colonoscopy-following-positive-cologuard-result) Jun 24, 2026 [Industry News](https://hiacode.com/blog/tag/industry-news),  [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) #### [20,000 Inpatient Reviews Reveal Coding Opportuniti...](https://hiacode.com/blog/20k-inpatient-coding-reviews-principal-diagnosis-pcs-revenue-integrity) A review of 20,805 inpatient encounters found... [ Read More](https://hiacode.com/blog/20k-inpatient-coding-reviews-principal-diagnosis-pcs-revenue-integrity) Jun 10, 2026 [Industry News](https://hiacode.com/blog/tag/industry-news),  [Medical Coding Tips](https://hiacode.com/blog/tag/medical-coding-tips) #### [Big Changes Coming to CPT Coding for Maternity Car...](https://hiacode.com/blog/big-changes-coming-to-cpt-coding-for-maternity-care) Beginning January 1, 2027, CPT will retire th... [ Read More](https://hiacode.com/blog/big-changes-coming-to-cpt-coding-for-maternity-care) ## Subscribe to our Newsletter Weekly medical coding tips and coding education delivered directly to your inbox. ```json { "@context" : "https://schema.org", "@type" : "BlogPosting", "author" : { "@type" : "Person", "name" : "HIAcode", "url" : "https://hiacode.com/blog/author/hiacode" }, "dateModified" : "2024-01-31T16:44:19.583Z", "datePublished" : "2022-08-13T04:00:00.000Z", "headline" : "Sequencing of the Principal Procedure", "image" : [ "https://hiacode.com/hubfs/Imported_Blog_Media/iStock-506138196-1.jpg" ], "mainEntityOfPage" : { "@id" : "https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "url" : "https://hiacode.com/hubfs/HIA_RGB_AlternativeLogo%20(1)%20(1).png" }, "name" : "Health Information Associates" } } ``` ```json { "@context" : "http://schema.org", "@type" : "Article", "author" : { "@type" : "Person", "name" : "Kim Boy, RHIT, CDIP, CCS, CCS-P", "url" : "https://hiacode.com/blog/author/kim-boy" }, "dateModified" : "2023-03-10", "datePublished" : "2022-08-13", "description" : "The procedure that is performed for definitive treatment or is taking care of a complication is the principal procedure.", "headline" : "Sequencing of the Principal Procedure", "image" : "https://20824215.fs1.hubspotusercontent-na1.net/hubfs/20824215/Imported_Blog_Media/iStock-506138196-1.jpg", "mainEntityOfPage" : { "@id" : "https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "height" : "60", "url" : "https://hiacode.com/hubfs/Logos/Health%20Information%20Associates%20Medical%20Coding%20Company.png", "width" : "60" }, "name" : "Health Information Associates" }, "url" : "https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure" } ``` ```json { "@context" : "http://schema.org", "@type" : "BlogPosting", "author" : { "@type" : "Person", "name" : "Kim Boy, RHIT, CDIP, CCS, CCS-P", "url" : "https://hiacode.com/blog/author/kim-boy" }, "dateModified" : "2023-03-10", "datePublished" : "2022-08-13", "description" : "The procedure that is performed for definitive treatment or is taking care of a complication is the principal procedure.", "headline" : "Sequencing of the Principal Procedure", "image" : "https://20824215.fs1.hubspotusercontent-na1.net/hubfs/20824215/Imported_Blog_Media/iStock-506138196-1.jpg", "mainEntityOfPage" : { "@id" : "https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "height" : "60", "url" : "https://hiacode.com/hubfs/Logos/Health%20Information%20Associates%20Medical%20Coding%20Company.png", "width" : "60" }, "name" : "Health Information Associates" }, "url" : "https://hiacode.com/blog/education/coding-tip-sequencing-of-the-principal-procedure" } ```