What is the Uhdds definition of principal diagnosis?
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”.
What are Uhdds requirements?
Medical billing and coding professionals will recognize the following information as being required on today’s UHDDS forms:
- Hospital or facility identification number or code.
- Expected insurance payer number or code.
- Sex, age, and race of the patient.
- Significant medical procedures performed.
- Principal diagnosis.
How is Uhdds used?
The Uniform Hospital Discharge Data Set, or UHDDS, is used for reporting inpatient data in acute-care, short-term care, and long-term care hospitals.
Do you code diagnosis or procedures first?
a. Sequence diagnostic procedure as principal procedure, since the procedure most related to the principal diagnosis takes precedence.
What is the Uhdds definition of other diagnoses quizlet?
What is the UHDDS definition of other diagnoses? Conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.
What data elements are unique to Uhdds?
The unique number assigned to each patient within a hospital that distinguishes the patient and his or her hospital record from all others in that institution.
Who developed Uhdds?
Standardized data sets, starting with the UHDDS developed by the NCVHS, have been in use for more than two decades.
What is the difference between procedure and diagnosis codes?
2. The CPT code describes what was done to the patient during the consultation, including diagnostic, laboratory, radiology, and surgical procedures while the ICD code identifies a diagnosis and describes a disease or medical condition.
What are the procedure for coding?
6 Key Steps in the Medical Coding Process
- Action 1. Abstract the documentation.
- Action 2. Query, if necessary.
- Action 3. Code the diagnosis or diagnoses.
- Action 4. Code the procedure or procedures.
- Action 5. Confirm medical necessity.
- Action 6. Double-check your codes.
How does the Uhdds define a comorbidity?
A comorbidity is an additional diagnosis that describes a preexisting condition that because of its presence with a specific principal diagnosis will likely cause an increase in the patient’s length of stay in the hospital.
In what setting does the Uhdds definition of principal diagnosis not apply?
The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits. 1. In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.
Which of the following are components of ahima’s principles of information governance?
What are the components of AHIMA’s principles of information governance? Accountability and integrity. Data stewardship is defined as principles and practices established to ensure the knowledgeable and appropriate use of data derived from individuals’ personal health information.
What is the principal diagnosis in uhdds?
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as ‘that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. What is hospital discharge data?
What is uhdds?
Hospital’s identification 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,
What information is required on the uhdds form?
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
What is the uniform hospital discharge data set uhdds?
Implemented in 1974, the Uniform Hospital Discharge Data Set (UHDDS) was originally an initiative by the predecessor of today’s Department of Health and Human Services (HHS), the Department of Health, Education, and Welfare. Likewise, what is the Uniform Hospital Discharge Data Set Uhdds how does it relate to medical coding?