Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015

Transcript:Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015:
Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition Chapter 3: Introduction to the Uniform Hospital Discharge Data Set and Official Coding Guidelines 2 Learning Objectives Review the chapter’s learning objectives Concepts in this chapter may require extra time to study Recognize the importance of learning about: UHDDS elements including principal diagnosis, other diagnoses, complication, comorbidity, significant procedure, and principal procedure definitions Uniform Bill 04 Official coding guidelines 3 UHDDS Uniform Hospital Discharge Data Set Minimum, common core set of data Originally intended for acute care, short-term hospitals Application of UHDDS definitions has been expanded to include all non-outpatient settings, including acute care, short term, long-term care, and psychiatric hospitals; home health agencies, rehab facilities, nursing homes, and such 4 UHDDS Data Elements Specific items regarding patients and their care: Personal identification number: health record number Date of birth Sex Race Ethnicity (Hispanic/Non Hispanic) Residence: zip code or code for foreign residence 5 UHDDS Data Elements (continued) Specific items (continued) Hospital identification: provider number Admission and discharge dates Physician identification: physician number Disposition of patient Expected payer for most of the bill 6 UHDDS Data Elements (continued) Clinical information is part of UHDDS All diagnoses affecting the current hospital stay must be reported All significant procedures, dates, and person performing the procedure must be reported Definition of principal and secondary diagnosis and procedure included in UHDDS 7 Principal and Other Diagnoses Principal diagnosis The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care Other diagnoses All conditions that coexist at the time of admission, that develop subsequently, or that affect treatment received and/or length of stay 8 Complications and Comorbidities A complication or comorbidity is defined as additional diagnosis that may have an impact on the payment received through the Medicare-severity diagnosis-related group (MS-DRG) inpatient acute care prospective payment system from Medicare 9 Significant Procedure Significant procedure All significant procedures are to be reported A procedure is identified as significant when it: Is surgical in nature Carries a procedural risk Carries an anesthetic risk Requires specialized training 10 Principal Procedure Principal procedure Procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes or is necessary to take care of a complication If two procedures appear to be principal, the one most related to the principal diagnosis should be selected 11 UHDDS Data Elements Complication An additional diagnosis