Uniform Hospital Discharge Data Set (UHDDS) Chap.4 All Possible Questions and Answers with complete solution

Admission Following Postoperative Observation - *A patient undergoing outpatient surgery may require postoperative admission to an observation unit to monitor a condition that develops postoperatively.* Principal Diagnosis and " After study" - *The principal diagnosis is NOT the admitting diagnosis* BUT the diagnosis found after workup or surgery that proves to be the reason for admission. UHDDS application - Definitions and guidelines for selection of principal diagnosis and other (secondary) diagnoses apply to: *Acute care short-term hospitals* *Long-term care hospitals*, *Psychiatric hospitals*, *Home health agencies* *Rehabilitation facilities*, *Nursing homes, and other settings*. Uniform Hospital Discharge Data Set (UHDDS) - Used for reporting inpatient data in *acute care, short-term care, and long-term care hospitals.* Minimum set of items based on standard definitions to provide consistent data for multiple users. Required for reporting Medicare and Medicaid patients.Many other health care payers use UHDDS for the uniform billing system. UHDDS requiered data item - The UHDDS requires the following items: *Principal diagnosis* *Other diagnoses that have significance for the specific hospital episode* *All significant procedures.* Other items of general specific episode of care: *Age, sex, and race of the patient, Expected payer, and Hospital's identification* Principal Diagnosis- Definition and Importance - *Definition: The condition established after study to be chiefly responsible for admission of the patient to the hospital*. *Importance of correct selection:* Significant in cost comparisons, in care analysis, and in utilization review. Crucial for reimbursement because many third-party payers (including Medicare) *base reimbursement primarily on principal diagnosis*. *The principal diagnosis is ordinarily listed first in the physician's diagnostic statement*, *but this is not always the case.* 1+ Always review the entire medical record2+ determine the condition that should be designated as the principal diagnosis. Selection of Principal Diagnosis - The *circumstances* of inpatient admission always govern the selection of the principal diagnosis. *Coding directives* in the ICD-10-CM classification take precedence over all other guidelines. Admission Following Medical Observation - *A patient may be treated in a hospital's observation unit to determine if the condition improves sufficiently for the patient to be discharged*. If the condition either worsens or doesn't improve, the physician may decide to admit the patient as an *inpatient*. *Principal diagnosis: Report the medical condition that led to the hospital admission.* If the patient doesn't improve, the physician may admit the patient to the same hospital as an *inpatient* *Principal diagnosis*: Apply UHDDS definition of principal diagnosis— *"that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."*