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Uniform Hospital Discharge Data Set UHDDS
questions with correct answers
MS-DRG - Correct Answer-Medicare severity-adjusted diagnosis-related group system Other reportable diagnoses - Correct Answer-conditions that coexist at the time of admission, develop subsequently, or affect patient care during the hospital stay Principal Diagnosis - Correct Answer-the condition established after study that is chiefly responsible for admission of the patient to the hospital 6 Items always found in UHDDS - Correct Answer-General demographic information Expected Payer Hospital identification Principal diagnosis Other diagnoses that have sp. significance All significant procedures UHDDS used to report inpatient data in: - Correct Answer-acute care short-term care hospitals long-term care hospitals
psychiatric hospitals home health agencies rehabilitation facilites nursing homes Patient admitted to hospital from observation unit principal diagnosis will be: (one bill) - Correct Answer-The medical condition that led to the hospital admission Patient admitted to hospital from postoperative observation, principal diagnosis will be: (one bill) - Correct Answer-condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care Patient admitted from outpatient surgery due to complication, principal diagnosis is: - Correct Answer-Complication Patient admitted from outpatient surgery with NO complication or other condition documented, principal code is: - Correct Answer-reason for outpatient surgery Patient admitted from outpatient surgery for condition unrelated to surgery, the principal code is: - Correct Answer-unrelated condition Admission/Encounters for rehabilitation, the principal code is: - Correct Answer- the condition for which the rehabilitation service is being performed. Example: Admitted for rehabilitation for right-sided dominant hemiplegia following a cerebrovascular infarction, report code I69.351, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
--Increased nursing care and/or other monitoring Do NOT code other diagnoses: - Correct Answer---Previous conditions stated as diagnoses --other diagnosis within documentation supporting reportability --chronic conditions that are NOT the thrust of treatment --Conditions that are an integral part of a disease process --abnormal findings alone DO code other diagnoses: - Correct Answer---historical conditions that have an impact on current care or influences treatment --Some chronic conditions that affect the patient for the rest of life --chronic conditions that require or affect patient care treatment or management --Conditions that are not an integral part of a disease process when present --abnormal finding considered to be clinically significant by listing in diagnostic statement Admitting diagnosis: - Correct Answer---significant finding representing patient distress or an abnormal finding on outpatient examination --possible diagnosis based on significant findings --diagnosis established on an ambulatory care basis or during a previous hospital admission. --injury or poisoning --reason or condition that is not actually an illness or injury....follow-up examination or pregnancy in labor Principal Diagnosis for Long-Term Care is: - Correct Answer-condition that is chiefly responsible for the admission to or continued residence in a nursing facility
Ethical Coding and Reporting - Correct Answer---Correct designation of the principal diagnosis --presence or absence of additional codes that represent complications, comorbidities, or major complication or comorbidities as defined by the Medicare- severity-adjusted diagnosis-related groups system --procedures performed Over-coding and over-reporting is considered - Correct Answer-fraudulent Under-reporting and under-coding - Correct Answer-loss of revenue
