Uhdds Study guides, Class notes & Summaries

01. Personal Identification - Correct Answer-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. 02. Date of Birth - Correct Answer-Month, day, and year of birth. Capture of the full four-digit year of birth is recommended 03. Sex - Correct Answer-Male or female 04. Race and ethnicity - Correct Answer-04a. Race American Indian/Eskimo/Aleut Asian or Pacific Islander Black W...

Other diagnosis with no supporting documentation - The physician should be queried as to whether the included diagnosis meets reporting criteria, and if so, the physician should add the necessary supporting documentation to the medical record. Admission from outpatient surgery - 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 sur...

What is the UHDDS definition of principal diagnosis? - The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. What is the difference between a "complication" and a "comorbidity" ? - A complication is an additional diagnosis that describes a condition arising after the beginning of the hospital observation and treatment and then modifying the course of the patient's illness or the medical care required. A co...

Uniform Hospital Discharge Data Set (UHDDS) questions with correct answers

Qualifier for other diagnoses - A qualifier is given for each diagnosis coded under "other diagnoses" to indicate whether the onset of the diagnosis preceded or followed admission to the hospital. The option "uncertain" is permitted. Present on Admission requirement. Admission Date - Month, day, and year. Clarification is added to this data item to note that for emergency and observation type patients, the time of admission is guided by the time that the physician gives the order to adm...

5 POA Condition Choices - •Y Yes (present at the time of inpatient admission) •N No (not present at the time of inpatient admission) •U Unknown (documentation is insufficient to determine if condition is present on admission) •W Clinically undetermined (provider is unable to clinically determine whether condition was present on admission or not. •Unreported/not used: Exempt from POA reporting (This option is the only circumstance in which the POA field is left blank. The conditio...

Previous conditions - If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy. However, history codes (categories Z80-Z87) may be...

UHDDS Definitions Study Set questions with correct answers

What it UHDDS? - Answer A set of defined data items used for reporting inpatient data in acute-care, short term, and long term care hospitals. Consistent definitions of data items provides consistent data for multiple users. -Easily identified -Readily defined -Uniformly recorded -Easily abstracted from the medical record Required for reporting Medicare and Medicaid patients. History and Development of UHDDS - Answer Promulgated by the United States Department of Health, Ed...

Uniform Hospital Discharge Data Set (UHDDS) - Answer 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 - Answer The UHDDS requires the following items: Principal diagnosis, ...