Coding Ch 3

UHDDS
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.

UHDDS Data Elements
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

UHDDS Data Elements (continued)
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

…UHDDS Data Elements (continued) b
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

Principal and Other Diagnoses
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

Principal procedure
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

Significant procedure
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

Complications and Comorbidities
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

UHDDS Data Elements
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

Uniform Bill-04
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

Expanded Number of Codes – 1/1/2011
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.

…Expanded Number of Codes – 1/1/2011 b
25 diagnosis codes with associated present on admission indicator
1 Principal diagnosis
24 Additional diagnosis
25 procedure codes

Present on Admission (POA)
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

Present on Admission (POA) b…
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

Principal Diagnosis Definition
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

Selection of Principal Diagnosis
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

Official ICD-9-CM Guidelines
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

Official ICD-9-CM Guidelines – Principal Diagnosis
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

Official ICD-9-CM Guidelines – Principal Diagnosis (continued)
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

Official ICD-9-CM Guidelines – Principal Diagnosis (continued) b
Review principal diagnosis guidelines for:
Complications of surgery or other medical care
Uncertain diagnosis
Admission from observation unit
Admission from outpatient surgery

Official ICD-9-CM Guidelines – Additional Diagnosis
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

ICD-10-CM Official Guidelines for Coding and Reporting
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

ICD-10-CM Official Guidelines for Coding and Reporting
Developed by the Cooperating Parties
(AHA, AHIMA, CMS, NCHS)
Section III
Reporting of additional diagnoses
Section IV
Guidelines for outpatient coding and reporting

ICD-10-CM Official Guidelines for Coding and Reporting
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

Tagged In :

Get help with your homework


image
Haven't found the Essay You Want? Get your custom essay sample For Only $13.90/page

Sarah from studyhippoHi there, would you like to get such a paper? How about receiving a customized one?

Check it out