Chapter 3 Introduction to the Uniform Hospital Discharge Data Set and Official ICD-10-CM Coding Guidelines Review Exercises: Chapter 3 Questions And Answers Rated A+ New Update Assured Satisfaction

1.What is the purpose of the Uniform Hospital Discharge Data Set? What healthcare organizations collect UHDDS? - To establish a minimum common core of data to be collected on individual acute care short-term hospital discharges in Medicare and Medicaid programs. UHDDS sought to improve the uniformity and comparability of hospital discharge data. All nonoutpatient settings including acute care, short-term care, long-term care, and psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes 2.What is the UHDDS definition of principal diagnosis? - 3.What is the UHDDS definition of principal procedure? - The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes, or when it is necessary to take care of a complication. The procedure most related to the principal diagnosis should be selected. 4.According to the UHDDS, how is the principle diagnosis selected? - 5.What is the maximum number of diagnosis and procedure codes that can be processed on institutional claims through version 5010/837I of the electronic claims transaction standards? - Inpatient Claims: 25 diagnosis codes (one principal diagnosis and 24 additional diagnoses) and a total of 25 procedure codes for institutional electronic claims processing. 6.According to the Section IV: Diagnostic coding and reporting guideline for Outpatient Services, how does the first listed diagnosis in the outpatient setting differ from the selection of the principal diagnosis in the Inpatient Setting? -For exercises 7-16: Apply the ICD-10-CM Official Guidelines for Coding and Reporting of the Principal Diagnosis for Inpatient Care (Guidelines II A-J) to identify the principal diagnosis in the following scenarios. - 7.Patient was admitted to the hospital after having a seizure at work. The admitting diagnosis was to rule out epilepsy. After testing was performed, the cause of the seizure was not determined, as the physician stated the patient did not have epilepsy. - Principal diagnosis = seizure 8.Patient was admitted to the hospital with acute pyelonephritis and acute cystitis. Both infections were evaluated and treated with intravenous antibiotic therapy. The patient was discharged home to continue taking oral medications. - 9.Patient was admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease and acute low back pain. Both conditions were evaluated, and the patient received medical treatment. The patient was discharged home to continue to receive physical therapy for the back pain and pulmonary rehabilitation therapy for his chronic lung disease. - Principal diagnosis could be either acute exacerbation of COPD or acute low back pain as the two diagnoses equally meet the definition of principal diagnosis. 10.The patient was admitted to the hospital with a multitude of gastrointestinal symptoms. After diagnostic tests were performed, the physician was unable to determine exactly what was causing the patient's symptoms. The physician's final diagnosis was "acute pancreatitis versus acute cholangitis." - 11.The patient was admitted to the hospital with left lower quadrant abdominal pain. After study, the physician concluded the patient's abdominal pain could have been due to either of two conditions. Her final diagnosis was abdominal pain due to either a ruptured ovarian cyst or acute salpingitis. - 12.The patient was admitted to the hospital for a total right knee replacement for osteoarthritis of the knee. During the patient's preoperative preparation, the patient began having chest pain. The patient's knee surgery was cancelled, and the patient had extensive testing to determine the source of the chest pain, which was determined to be due to hypertensive heart disease. -13.The patient was readmitted to the hospital for a postoperative wound infection. The patient had been discharged from the hospital five days ago, after having colon surgery for ruptured diverticulitis. During this hospital stay, the patient was treated for the wound infection and monitored for the remaining diverticulitis in his colon. - 14.The patient was admitted to the hospital with fever, cough, and shortness of breath. After study, the physician could not identify the exact cause of these symptoms but felt the most likely cause was pneumonia. The physician's final diagnosis was "possible viral pneumonia now resolving." - 15.The patient comes to the Emergency Department complaining of an asthma attack. The patient is placed into the observation unit to monitor his response to the asthma treatment. During the observation time, the patient is determined to have status asthmaticus and is admitted for treatment of this condition. After a three-day hospital stay, the patient's asthma is better controlled, and he is discharged. - 16.The patient was registered as an outpatient for a left-sided cataract extraction, which was performed successfully. While the patient was preparing to leave the hospital after surgery, the patient felt faint, and it was determined the patient's blood pressure was much lower than earlier in the day. The patient was admitted to the hospital to monitor the low blood pressure. The next day, the patient felt well again and was discharged. The physician described the patient's condition as "orthostatic hypotension." - For exercises 17-20: Apply the ICD-10-CM Official Guidelines for Coding and Reporting for Reporting Additional Diagnoses (Guideline Section III) to identify the other diagnosis/diagnoses in the following scenarios. 17.The physician's discharge summary includes the final diagnoses of (1) acute cholecystitis, with additional diagnosis of (2) cholelithiasis, (3) type II diabetes, (4) history of pneumonia last year, and (5) status post bunionectomy three months ago. - 18.The physician's discharge summary includes the final diagnoses of (1) coronary artery disease, (2) hypertension, and (3) benign prostatic hypertrophy. The coder notes in the patient's laboratory reports that the patient has an elevated cholesterol level and an elevated PSA positive finding. - 19.The physician's discharge summary includes the final diagnoses of (1) acute hemorrhagic gastritis, (2) acute duodenitis, and (3) possible acute pancreatitis. -20.The patient was admitted to the hospital with acute abdominal pain that was determined to be due to acute appendicitis, and the surgeon performed an open appendectomy on the patient. During the recovery period, the patient experienced two episodes of urinary retention that required the placement of a temporary urinary catheter. Would the second diagnosis of urinary retention be reported with a "yes" or a "no" as present on admission? -