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Chapter 3 Intro to Uhdds and ICD-10-CM Guidelines - Notes

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ICD Diagnosis Coding (10530197)

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Mid-State Technical College

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Chapter 3 Intro to the UHDDS and Official ICD-10-CM Coding Guidelines

Uniform Hospital Discharge Data Set  In order for the data to be useful, everyone gathering the data must collect the same data the same way.  UHDDS was promulgated by the US Department of Health, Education, and Welfare in 1974 as a minimum, common core of data on individual acute care short-term hospital discharges in Medicare and Medicaid programs.  In 1985, the data set was revised to improve the original version in light of timely needs and developments. Since then, UHDDS definitions has been expanded to include all nonoutpatient settings.  Part of the current UHDDS includes the following specific items pertaining to patients and their episodes of care: o Personal identification: the unique number assigned to each patient that distinguishes the patient and his or her health record from all others o Date of birth o Sex o Race o Ethnicity (Hispanic-Non-Hispanic) o Resident: The zip code or code foreign residence o Hospital identification: the unique number assigned to each instiution o Admission and discharge dates o Disposition of patient: the destination of the patient upon leaving the hospital – discharge to home, left against medical advice, discharge to another short-term hospital, discharged to a long-term care institution, died, or other o Expected payer: the single major source expected by the patient to pay for this bill  In keeping with UHDDS standards, medical data items for the following diagnoses and procedures also are reported: o Diagnoses: All diagnoses affecting the current hospital stay must be reported as part of the UHDDS o Principal Diagnosis: The principal diagnosis is designated and defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care o Other Diagnoses: These are designated and defined as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay (LOS). Diagnoses are to be excluded that relate to an earlier episode that has no bearing on the current hospital stay. Within Medicare Acute Care Inpatient Prospective Payment System (IPPS), other diagnoses may qualify as a major complication or comorbidity (MCC), or other complication or comorbidity (CC). The terms complication and comorbidity are not part of the UHDDS definition set but were developed as part of the diagnoses-relates group (DRG) system. The presence of the complication or comorbidity may influence the MS-DRG assignment and produce a higher-valued DRG with a higher payment for the hospital.

Chapter 3 Intro to the UHDDS and Official ICD-10-CM Coding Guidelines

o Complication: This is defined as an additional diagnosis that describes a condition arising after the beginning of hospital observation and treatment and then modifying the course fo the patient’s illness or the medical care required. o Comorbidity: This is defined as pre-existing condition that, because of its presence with a special principal diagnosis, will likely cause an increase in the patient’s length of stay in the hospital o Procedures and dates: All significant procedures are to be reported. For significant procedures, both the identity of the person performing the procedure and the date of the procedure must be reported. o Significant Procedure: A procedure is identified as significant when it (nonsignificant procedures are usually not coded)  Is surgical in nature  Carries a procedural risk  Carries an anesthetic risk  Requires specialized training o Principal Procedure: this type of procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes, or when it 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 as the principal procedure. Selection of Principal Diagnosis  UHDDS states, a principal diagnosis is the condition “established after study to be chiefly responsible for occasioning the admission of the patient ot the hospital for care”  Selecting the principal diagnosis depends on the circumstances of the admission, or why the patient was admitted.  The words “after study” serve as an integral part of this definition. o Ex. Patient was admitted through the emergency department with an admitting diagnosis of seizure disorder. During hospitalization, diagnostic tests and studies revealed carcinoma of the brain, which explained the seizures.  The principal diagnosis was the carcinoma of the brainm which was the condition determined after study.  At times, it may be difficult to distinguish between the the principal diagnosis and the most significant diagnosis. The most significant diagnosis is defined as the condition having the most impact on the patient’s health, LOS, resource consumption, and the like. Howeverm the most significant diagnosis may or may not be the principal diagnosis. o Ex. Patient was admitted with a fractured hip due to an accident. The fracture was reduced and the patient discharge home.  In this case, the principal diagnosis was fracture of the hip. o Ex. Patient was admitted with a fractured hip due to an accident. While hospitalized, the patient suffered a myocardial infarction.  In this case, the principal diagnosis was still the fracture of the hip, with the myocardial infarction coded as an additional diagnosis.

Chapter 3 Intro to the UHDDS and Official ICD-10-CM Coding Guidelines

even though treatment may not have been carried out due to unforeseen circumstances.  Guideline II. Complications of surgery and other medical care: when the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to T80-T88 series, and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.  Guideline II. Uncertain diagnosis: if the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely the established diagnosis. ( This guideline is applicable only to inpatient admissions to short-term, acute care, long-term care, and psychiatric hospitals.)  Guideline II Admission from outpatient surgery: When a patient receives surgery in the hospital’s outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission:  If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis  If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.  If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis. o Guideline II. Admissions/Encounters for Rehabilitation: When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed.  If the condition for which the rehabilitation service is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis, unless the rehabilitation service is being provided following an injury. For rehabilitation services following active treatment of an injury, assign the injury code with the appropriate seventh character for subsequent encounter as the first-listed or principal diagnosis. Reporting of Additional Diagnoses  In the definition of “other diagnoses,” conditions that require clinical evaluation are to be coded. Clinical evaluation usually means the physician has taken the condition into consideration when examining the patient.  The sequencing of the additional diagnoses is not mandated by a particular coding guideline.  For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring one of the five factors about the patient care:

Chapter 3 Intro to the UHDDS and Official ICD-10-CM Coding Guidelines

o Clinical evaluation o Therapeutic treatment o Diagnostic procedures o Extended length of hospital stay; or o Increased nursing care or monitoring.  The UHDDS item #11-B defines other diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that are relate to an earlier episode that have no bearing on the current hospital stay are to be exclude.” UHDDS definitions apply to inpatients in acute care, short- and long- term care, and psychiatric hospital settings. The UHDDS definitions are used by acute care short-term hospitals to report inpatient data in a standardized manner.  Has now been expanded to include all nonoutpatient settings as well hospice services.  Following guidelines are to be applied in designating “other diagnoses” when neither the Alphabetic Index nor the Tabular List in ICD-10-CM provide directions. The listing of the diagnoses in the patient record is the responsibility of the attending provider. o Guideline III. Previous conditions: If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. However, history code (Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment o Guideline III. Abnormal findings: abnormal finding are not coded and reported unless the provider indicates their clinical significance o Guideline III. Uncertain diagnosis: if the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. NOTE: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals. Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services  Coding of healthcare services in an outpatient setting is different from the coding of patients’ diagnoses provided in an inpatient setting. Outpatient encounters are often short visits, and there is not a lot of time to study the patient’s condition in depth.  This section addresses the general rules for diagnostic coding and reporting guidelines for outpatient services (can be found in appendix F)  UHDDS definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits  Coding guidelines for inconclusive diagnoses were developed for inpatient reporting and do not apply to outpatients. o Selection of first-listed condition: In outpatient setting, the term first-listed Dx is used in lieu of principle diagnosis. When determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precendence over the outpatient guidelines.

Chapter 3 Intro to the UHDDS and Official ICD-10-CM Coding Guidelines

or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for the encounter/visit, such as symptoms, signs, abnormal tst results, or other reason for the visit. NOTE: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals. o Chronic diseases: treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s). o Code all documented conditions that coexist: at the time of the encounter/visit and required or affect patient care treatment of management. Do not code conditions that were previously treated and no longer exist. However history codes (Z80-Z87) may be used as secondary codes if the historical condition or family hisptry has an impact on current care or influences treatment. o Patients receiving diagnostic services only: during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses may be sequenced as additional diagnoses.  If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test  For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. NOTE: this differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results o Patients receiving therapeutic services only: during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient srvices provided during the encounter/visit. Codes for other diagnoses may be sequenced as additional diagnoses.  Only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second. o Patients recieivng preoperative evaluations only: sequence first a code from subcatefory Z01, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation. o Ambulatory surgery: code the diagnosis for which the surgery was performed. If the postoperatived diagnosis is known to be different from the

Chapter 3 Intro to the UHDDS and Official ICD-10-CM Coding Guidelines

preoperative diagnosis at the the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

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Chapter 3 Intro to Uhdds and ICD-10-CM Guidelines - Notes

Course: ICD Diagnosis Coding (10530197)

23 Documents
Students shared 23 documents in this course

University: Mid-State Technical College

Was this document helpful?
ICD Diagnosis
Chapter 3 Intro to the UHDDS and Official ICD-10-CM Coding Guidelines
Uniform Hospital Discharge Data Set
In order for the data to be useful, everyone gathering the data must collect the same data
the same way.
UHDDS was promulgated by the US Department of Health, Education, and Welfare in 1974
as a minimum, common core of data on individual acute care short-term hospital discharges
in Medicare and Medicaid programs.
In 1985, the data set was revised to improve the original version in light of timely needs and
developments. Since then, UHDDS definitions has been expanded to include all
nonoutpatient settings.
Part of the current UHDDS includes the following specific items pertaining to patients and
their episodes of care:
oPersonal identification: the unique number assigned to each patient that distinguishes
the patient and his or her health record from all others
oDate of birth
oSex
oRace
oEthnicity (Hispanic-Non-Hispanic)
oResident: The zip code or code foreign residence
oHospital identification: the unique number assigned to each instiution
oAdmission and discharge dates
oDisposition of patient: the destination of the patient upon leaving the hospital –
discharge to home, left against medical advice, discharge to another short-term hospital,
discharged to a long-term care institution, died, or other
oExpected payer: the single major source expected by the patient to pay for this bill
In keeping with UHDDS standards, medical data items for the following diagnoses and
procedures also are reported:
oDiagnoses: All diagnoses affecting the current hospital stay must be reported as part of
the UHDDS
oPrincipal Diagnosis: The principal diagnosis is designated and defined as the condition
established after study to be chiefly responsible for occasioning the admission of the
patient to the hospital for care
oOther Diagnoses: These are designated and defined as all conditions that coexist at the
time of admission, that develop subsequently, or that affect the treatment received or
the length of stay (LOS). Diagnoses are to be excluded that relate to an earlier episode
that has no bearing on the current hospital stay. Within Medicare Acute Care Inpatient
Prospective Payment System (IPPS), other diagnoses may qualify as a major
complication or comorbidity (MCC), or other complication or comorbidity (CC). The
terms complication and comorbidity are not part of the UHDDS definition set but were
developed as part of the diagnoses-relates group (DRG) system. The presence of the
complication or comorbidity may influence the MS-DRG assignment and produce a
higher-valued DRG with a higher payment for the hospital.

Students also viewed

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