Understanding Hospital Discharge Data Set & Coding Guidelines

1. Basic ICD-10-CM/PCS Coding2013 Edition Chapter 3: Introduction to the Uniform Hospital Discharge Data Set and Official ICD-10-CM Coding Guidelines

2. Learning Objectives • Review the chapter’s learning objectives and key terms • Concepts in this chapter require extra time to study and understand • 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 or 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. UHDDS Data Elements • Complication • 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 • Comorbidity • A pre-existing condition that, because of its presence with a specific principal diagnosis, will cause an increase in the patient’s length of stay

10. Procedures and Dates • Procedures and Dates • All significant procedures are to be reported • Both the identify of the person performing the procedure and the date of the procedure must be reported

11. Significant Procedure • Significant procedure • A procedure is identified as significant when it: • Is surgical in nature • Carries a procedural risk • Carries an anesthetic risk • Requires specialized training

12. 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

13. Uniform Bill-04 • See figure 3.1 for sample UB-04 institutional paper claim form, electronic claims version 4010 (also on ahimapress.org) • Used for Medicare Part A and other payer claims from hospitals and other healthcare institutions (home care, skilled nursing facility care) • Eighteen final diagnosis codes • In addition, there are spaces for: • One admitting diagnosis, • Three reason for visit diagnoses, • Three E-codes • Six procedure codes and dates

14. Expanded Number of Codes • Effective 1/1/2011, CMS expanded the number of ICD-9-CM diagnosis and procedure codes allowed to be processed on institutional claims through the implementation of version 5010/837I of the electronic claims transaction standards for institutional claims.

15. Expanded Number of Codes • Electronic institutional claims • 25 diagnosis codes with associated present on admission indicator • 1 Principal diagnosis • 24 Additional diagnosis • 25 procedure codes

16. Present on Admission (POA) • Diagnosis “indicator” to be reported with each diagnosis code—was condition present on admission? • Four choices: • Yes • No • Documentation insufficient • Clinically undetermined • Reported for discharges from acute care hospitals or other facilities as required by law or public health reporting

17. Present on Admission (POA) • Comprehensive POA guidelines are included in the “ICD-10-CM Official Guidelines for Coding and Reporting” • Guidelines were created by The Cooperating Parties for ICD-10-CM • The Cooperating Parties are four representatives of AHIMA, American Hospital Association, CMS and National Center for Health Statistics

18. Principal Diagnosis Definition • Principal diagnosis is “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” • Principal diagnosis relates only to inpatient care • Specific guidelines must be followed

19. Selection of Principal Diagnosis • Relates only to all inpatient settings to report patient data • Not applied to coding of outpatient visits • Depends on circumstances of admission • Related to but not the same as admitting diagnosis • Key words “after study” are integral part of the principal diagnosis definition

20. Official ICD-10-CM Guidelines • Official ICD-9-CM guidelines for coding and reporting are used to select principal and other diagnoses • Guidelines printed in most publishers’ versions of ICD-10-CM code books • Guidelines included in Appendix E provided with this textbook’s materials

21. ICD-10-CM Official Guidelines for Coding and Reporting • Review the entire guidelines in the ICD-10-CM codebook or on the CDC website • Section I • Structure and conventions of ICD-10-CM and the general guidelines that apply to the entire classification system

22. ICD-10-CM Official Guidelines for Coding and Reporting • Section II • Principal diagnosis selection • Section III • Reporting of additional diagnoses • Section IV • Guidelines for outpatient coding and reporting

23. Official ICD-10-CM Guidelines—Principal Diagnosis • Textbook includes the guidelines labeled as “CG” for study • Review principal diagnosis guidelines for: • Codes for symptoms, signs, and ill-defined conditions • Two or more interrelated conditions, each potentially meeting the definition of principal diagnosis • Two or more diagnoses that equally meet the definition for principal diagnosis

24. Official ICD-10-CM Guidelines—Principal Diagnosis (continued) • Review principal diagnosis guidelines for: • Two or more comparative or contrasting conditions • A symptom(s) followed by contrasting/comparative diagnoses • Original treatment plan not carried out

25. Official ICD-10-CM Guidelines—Principal Diagnosis (continued) • Review principal diagnosis guidelines for: • Complications of surgery or other medical care • Uncertain diagnosis • Admission from observation unit • Admission from outpatient surgery

26. Official ICD-10-CM Guidelines—Additional Diagnosis • Reporting of additional diagnoses • All conditions that coexist at the time of the admission, that develop subsequently, or that affect the treatment received and/or the length of stay • Review additional diagnosis guidelines for: • Previous conditions • Abnormal findings • Uncertain diagnosis

27. Official ICD-10-CM Guidelines—Section IV • Diagnostic Coding and Reporting Guidelines for Outpatient Services • Section IV of the coding guidelines direct the coder on how to code patient visits in a hospital outpatient setting, physician’s office, or other ambulatory care center

28. Official ICD-10-CM Guidelines—Section IV • Selection of the “first-listed” condition • Codes available for use • Accurate reporting of the diagnosis codes • Codes that describe symptoms and signs • Encounters for circumstances other than a disease or injury

29. Official ICD-10-CM Guidelines—Section IV • Level of detail in coding • Code for the diagnosis, condition, or other reason for encounter/visit • Uncertain diagnosis = different rule for outpatient coding, condition not coded that is described as uncertain or probable, suspected, questionable, rule out, or other terms indicating uncertainty

30. Official ICD-10-CM Guidelines—Section IV • Chronic diseases • Code all documented conditions that coexist • Patients receiving diagnostic services only • Patients receiving therapeutic services only • Patients receiving preoperative evaluations only

31. Official ICD-10-CM Guidelines—Section IV • Ambulatory surgery • Routine outpatient prenatal visits • Encounters for general medical examinations with abnormal findings • Encounters for routine health screenings

32. ICD-10-CM Official Guidelines for Coding and Reporting • Review ICD-10-CM guidelines over and over! • Guidelines included with this book’s materials in Appendix E • Check website for most current version • www.cdc.gov/nchs/icd/icd10cm.htm • Complete the review exercises for Chapter 3