Coding Ch 3 – Flashcards
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UHDDS
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Uniform Hospital Discharge Data Set Minimum, common core set of data Originally intended for acute care, short-term hospitals Application of UHDDS definitions has been expanded to include all non-outpatient settings, including acute care, short term, long-term care, and psychiatric hospitals; home health agencies, rehab facilities, nursing homes, etc.
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UHDDS Data Elements
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Specific items regarding patients and their care: Personal identification number: health record number Date of birth Sex Race Ethnicity (Hispanic-Non Hispanic) Residence: zip code or code for foreign residence
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UHDDS Data Elements (continued)
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Specific items (continued) Hospital identification: provider number Admission and discharge dates Physician identification: physician number Disposition of patient Expected payer for most of the bill
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...UHDDS Data Elements (continued) b
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Clinical information is part of UHDDS All diagnoses affecting the current hospital stay must be reported All significant procedures, dates, and person performing the procedure must be reported Definition of principal and secondary diagnosis and procedure included in UHDDS
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Principal and Other Diagnoses
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Principal diagnosis The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care Other diagnoses All conditions that coexist at the time of admission, that develop subsequently, or that affect treatment received and/or length of stay
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Principal procedure
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Procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes or is necessary to take care of a complication If two procedures appear to be principal, the one most related to the principal diagnosis should be selected
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Significant procedure
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All significant procedures are to be reported A procedure is identified as significant when it: Is surgical in nature Carries a procedural risk Carries an anesthetic risk Requires specialized training
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Complications and Comorbidities
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A complication or comorbidity is defined as additional diagnosis that may have an impact on the payment received through the Medicare-severity diagnosis-related group (MS-DRG) inpatient acute care prospective payment system from Medicare
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UHDDS Data Elements
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Complication An additional diagnosis that describes a condition arising after the beginning of the hospital observation and treatment and then modifying the course of the patient's illness or the medical care required Comorbidity A pre-existing condition that, because of its presence with a specific principal diagnosis, will cause an increase in the patient's length of stay
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Uniform Bill-04
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See Appendix F for sample UB-04 institutional paper claim form, electronic claims version 4010 Used for Medicare Part A and other payer claims from hospitals and other healthcare institutions (home care, skilled nursing facility care) Eighteen diagnosis codes In addition, there are spaces for: One admitting diagnosis, Three reason for visit diagnoses, Three E-codes Six procedure codes and dates
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Expanded Number of Codes - 1/1/2011
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Effective 1/1/2011, CMS expanded the number of ICD-9-CM diagnosis and procedure codes allowed to be processed on institutional claims through the implementation of version 5010/837I of the electronic claims transaction standards.
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...Expanded Number of Codes - 1/1/2011 b
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25 diagnosis codes with associated present on admission indicator 1 Principal diagnosis 24 Additional diagnosis 25 procedure codes
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Present on Admission (POA)
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Diagnosis "indicator" to be reported with each diagnosis code - was condition present on admission? Four choices: Yes, No, Documentation insufficient, or Clinically undetermined Reported for discharges from acute care hospitals or other facilities as required by law or public health reporting
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Present on Admission (POA) b...
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Comprehensive POA guidelines are included in the "ICD-9-CM Official Guidelines for Coding and Reporting" Guidelines were created by The Cooperating Parties for ICD-9-CM The Cooperating Parties are four representatives of AHIMA, American Hospital Association, CMS and National Center for Health Statistics
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Principal Diagnosis Definition
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Principal diagnosis is "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care" Principal diagnosis relates only to inpatient care Specific guidelines must be followed
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Selection of Principal Diagnosis
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Relates only to all inpatient settings to report patient data Not applied to coding of outpatient visits Depends on circumstances of admission Related to but not the same as admitting diagnosis Key words "after study" are integral part of the principal diagnosis definition
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Official ICD-9-CM Guidelines
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Official ICD-9-CM guidelines for coding and reporting are used to select principal and other diagnoses Guidelines printed in most publishers' versions of ICD-9-CM code books Guidelines included in CD-ROM included in this textbook - Appendix I
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Official ICD-9-CM Guidelines - Principal Diagnosis
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Review principal diagnosis guidelines for: Codes for symptoms, signs, and ill-defined conditions Two or more interrelated conditions Two or more diagnoses that equally meet the definition for principal diagnosis
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Official ICD-9-CM Guidelines - Principal Diagnosis (continued)
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Review principal diagnosis guidelines for: Two or more comparative or contrasting conditions A symptom(s) followed by contrasting/comparative diagnoses Original treatment plan not carried out
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Official ICD-9-CM Guidelines - Principal Diagnosis (continued) b
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Review principal diagnosis guidelines for: Complications of surgery or other medical care Uncertain diagnosis Admission from observation unit Admission from outpatient surgery
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Official ICD-9-CM Guidelines - Additional Diagnosis
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Reporting of additional diagnoses All conditions that coexist at the time of the admission, that develop subsequently, or that affect the treatment received and/or the length of stay Review additional diagnosis guidelines for: Previous conditions Abnormal findings Uncertain diagnosis
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ICD-10-CM Official Guidelines for Coding and Reporting
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Developed by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) Section I Structure and conventions of ICD-10-CM and the general guidelines that apply to the entire classification system Section II Principal diagnosis selection
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ICD-10-CM Official Guidelines for Coding and Reporting
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Developed by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) Section III Reporting of additional diagnoses Section IV Guidelines for outpatient coding and reporting
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ICD-10-CM Official Guidelines for Coding and Reporting
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Review ICD-10-CM guidelines Version included on CD-ROM with this book in Appendix J Check website for most current version www.cdc.gov/nchs/icd/icd10cm.htm
