Chapter 4: UHDDS (Questions & Answers) Rated 100%

Other diagnosis with no supporting documentation - The physician should be queried as to whether the included diagnosis meets reporting criteria, and if so, the physician should add the necessary supporting documentation to the medical record. Admission from outpatient surgery - If due to complication, assign the complication as the principal diagnosis. If no complication or other reason, assign the reason for outpatient surgery as the principal diagnosis. If for condition unrelated to surgery, assign the unrelated condition as the principal diagnosis. UHDDS - Uniform Hospital Discharge Data Set used for reporting inpatient data in acute care, short-term care, and long-term care hospitals principal diagnosis - the condition established after study to be chiefly responsible for admission of the patient to the hospital Admission following medical observation - The principal diagnosis is the medical condition that led to the hospital admission. Admission following postoperative observation - Use the UHDDS definition to assign principal diagnosis Admissions/encounters for rehabilitation - Assign the condition for which service is being performed as the principal diagnosis. Assign the appropriate aftercare code as the principal diagnosis if the condition is no longer present. 2 or more conditions that equally meet principal diagnosis - Either condition may be sequenced first when neither the Alphabetic Index nor the Tabular List directs otherwise, except when treatment is totally or primarily directed toward one condition or when one of the conditions would have required inpatient care, that condition should be coded as the principal diagnosis.2 or more comparable/contrasting conditions - Both diagnoses are coded as confirmed, but the principal diagnosis is designated according to the circumstances of the admission and the diagnostic workup and/or treatment provided. (applies to inpatients only) Symptom followed by contrasting/comparative diagnosis - The symptom code is sequenced first, unless the symptom is integral to the condition(s) listed, which negates the reporting of the symptom code altogether. Original treatment plan not carried out - The principal diagnosis will still be the reason for the admission, regardless of whether or not the intended treatment was performed. Previous conditions stated as diagnosis - Any such previous diagnoses that have no bearing on the current admission are not reported. However, history codes may be used as secondary codes if the historical condition has an impact on the current care or treatment. Other diagnoses - those conditions that affect the episode of hospital care in terms of: clinical evaluation therapeutic treatment further evaluation by diagnostic studies extended the length of the hospital stay increased nursing care and/or monitoring admitting diagnosis - the physician's initial diagnosis of the patient upon admission to the hospital l Chronic conditions that are not the thrust of treatment - Chronic conditions can be assigned as other diagnoses based on: Severity of the condition Use or consideration of alternative measures Increase in nursing care of principal diagnosis due to chronic condition Need for close monitoring of meds b/c of chronic cond.Modifications of nursing plans b/c of chronic condition Life-long effects of chronic condition (hypertension, DM, Parkinson's, COPD are examples)