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. ICD Diagnosis
Chapter 3 Intro to the UHDDS and Official ICD-10-CM Coding Guidelines
oComplication: 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.
oComorbidity: 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
oProcedures 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.
oSignificant 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
oPrincipal 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.
oEx. 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.
oEx. 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.
oEx. 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
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. ICD Diagnosis
Chapter 3 Intro to the UHDDS and Official ICD-10-CM Coding Guidelines
oComplication: 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.
oComorbidity: 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
oProcedures 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.
oSignificant 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
oPrincipal 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.
oEx. 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.
oEx. 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.
oEx. 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.
