Ch. 3 UHDDS
5 POA Condition Choices - •Y Yes (present at the time of inpatient admission)
•N No (not present at the time of inpatient admission)
•U Unknown (documentation is insufficient to determine if condition is present on admission)
•W Clinically undetermined (provider is unable to clinically determine whether condition was present on
admission or not.
•Unreported/not used: Exempt from POA reporting (This option is the only circumstance in which the
POA field is left blank. The condition must be on the list of ICD-10-CM codes for which this field is not
applicable
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
)
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
Significant procedure - •Is surgical in nature
•Carries a procedural risk
•Carries an anesthetic risk
•Requires specialized training
Cooperating parties - Four organizations that approve guidelines: AHIMA, American Hospital
Association, CMS and National Center for Health Statistics
Complications and Comorbidities - is defined as additional diagnosis that may have an impact on
the payment received through the Medicare-severity diagnosis-related group (MS-DRG
5 POA Condition Choices - •Y Yes (present at the time of inpatient admission)
•N No (not present at the time of inpatient admission)
•U Unknown (documentation is insufficient to determine if condition is present on admission)
•W Clinically undetermined (provider is unable to clinically determine whether condition was present on
admission or not.
•Unreported/not used: Exempt from POA reporting (This option is the only circumstance in which the
POA field is left blank. The condition must be on the list of ICD-10-CM codes for which this field is not
applicable
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
)
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
Significant procedure - •Is surgical in nature
•Carries a procedural risk
•Carries an anesthetic risk
•Requires specialized training
Cooperating parties - Four organizations that approve guidelines: AHIMA, American Hospital
Association, CMS and National Center for Health Statistics
Complications and Comorbidities - is defined as additional diagnosis that may have an impact on
the payment received through the Medicare-severity diagnosis-related group (MS-DRG
