Uniform Hospital Discharge Data Set (UHDDS) Exam Study Guide

Uniform Hospital Discharge Data Set (UHDDS) Exam Study Guide Uniform Hospital Discharge Data Set (UHDDS) - Answer️️ -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 - Answer️️ -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 UHDDS application - Answer️️ -Originally developed for hospital reporting of inpatient data elements. Application of definitions expanded to all non-outpatient settings. ©SOPHIABENNETT EXAM SOLUTIONS_2024/2025 Monday, September 2, 2024 12:59 PM Page | 2 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. Principal Diagnosis- Definition and Importance - Answer️️ -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" - Answer️️ -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. ©SOPHIABENNETT EXAM SOLUTIONS_2024/2025 Monday, September 2, 2024 12:59 PM Page | 3 Selection of Principal Diagnosis - Answer️️ -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 Medical Observation - Answer️️ -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