Uniform Hospital Discharge Data Set (UHDDS) Questions and Answers Latest 2024/2025 with complete solutions

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. UHDDS application - Originally developed for hospital reporting of inpatient data elements. Application of definitions expanded to all non-outpatient settings. 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 also use most of the 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, and All significant procedures. Other items of general information regarding the patient and the 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. Principal Diagnosis and " After study" - The principal diagnosis is NOT the admitting diagnosis, but the diagnosis found after workup or even after surgery that proves to be the reason for admission. The principal diagnosis is ordinarily listed first in the physician's diagnostic statement, but this is not always the case. Always review the entire medical record to 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. Consistent, complete documentation in the medical record is important. Without such documentation, the application of all coding guidelines is a difficult, if not impossible, task. Admission Following Postoperative Observation - A patient undergoing outpatient surgery may require postoperative admission to an observation unit to monitor a condition (or complication) that develops postoperatively. 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."Admission from Outpatient Surgery - A patient undergoing outpatient surgery may subsequently be admitted for continuing inpatient care at the same hospital. The following guidelines should be followed in selecting the principal diagnosis for the inpatient admission: If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis. Admission from Outpatient Surgery Cont.... - If no complication or other condition is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis. If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis. Guidelines for Selection of Principal Diagnosis- Two or more conditions. - In the unusual situation in which two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of the admission and the diagnostic workup and/or therapy provided, either diagnosis may be sequenced first, unless the Alphabetic Index or the Tabular List directs otherwise Two or more conditions- Cont... - When treatment is totally or primarily directed toward one condition, or when only one condition would have required inpatient care, that condition should be designated as the principal diagnosis. If another coding guideline (general or disease-specific) provides sequencing direction, that guideline must be followed. Comparable or contrasting conditions - In the rare instance where two or more comparable or contrasting conditions are documented as either/or (or similar terminology), both diagnoses are coded as though confirmed, and the principal diagnosis is designated according to the circumstances of the admission and the diagnostic workup and/or therapy provided. When no further determination can be made as to which diagnosis more closely meets the criteria for principal diagnosis, either diagnosis may be sequenced first. Note: This does not apply to outpatient encounters.Symptom Followed by Contrasting/Comparative Diagnoses - When a symptom is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. However, if the symptom code is integral to the conditions listed, no additional code for the symptom is reported. Codes are assigned for all listed contrasting/comparative diagnoses.