Chapter 4: UHDDS Exam Study Guide.
UHDDS - answerUniform Hospital Discharge Data Set
used for reporting inpatient data in acute care, short-term care, and long-term care hospitals
principal diagnosis - answerthe condition established after study to be chiefly responsible for
admission of the pa...
UHDDS - answer✔✔Uniform Hospital Discharge Data Set
used for reporting inpatient data in acute care, short-term care, and long-term care hospitals
principal diagnosis - answer✔✔the condition established after study to be chiefly responsible for
admission of the patient to the hospital
Admission following medical observation - answer✔✔The principal diagnosis is the medical
condition that led to the hospital admission.
Admission following postoperative observation - answer✔✔Use the UHDDS definition to assign
principal diagnosis
Admission from outpatient surgery - answer✔✔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.
Admissions/encounters for rehabilitation - answer✔✔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 - answer✔✔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 - answer✔✔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)
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