ICD9 Medical Coding: UHDDS & Medical Record
Terms in this set (32)
Used for reporting inpatient data in acute, short term and long term care hospitals - uses a minimum set of items based on standard definitions.
identified, defined, recorded, abstracted from medical record
Items included in the UHDDS must be easily _____, readily _____, uniformly _____, and easily ______.
principal diagnosis, other significant diagnoses, all significant procedures
UHDDS requires what three items?
The condition established after study to be chiefly responsible for admission of the patient to the hospital.
cost comparisons, care analysis, utilization review, reimbursement
The principal diagnosis needs to be designated correctly because it can be significant in ______, _____, _____ and _____.
medical condition that led to hospital admission
If the patient is admitted following medical observation, the principal diagnosis reported would be the _______.
condition established after study
If the outpatient surgery patient is admitted following postoperative observation, the principal diagnosis reported would be the ______.
A patient undergoing outpatient surgery is admitted for inpatient care. If the reason for admission is a complication, assign ______ as principal diagnosis.
reason for outpatient surgery
A patient undergoing outpatient surgery is admitted for inpatient care. If no complication or other condition is document as reason for admission, assign _______ as the principal diagnosis.
A patient undergoing outpatient surgery is admitted for inpatient care. If the reason for admission is another condition unrelated to surgery, assign ______ as the principal diagnosis.
When two or more conditions that equally meet the definition of principal diagnosis, _____ may be sequenced first.
both conditions, circumstances of admission
When two or more comparable or contrasting conditions are documented as either/or, _______ are coded and the principal diagnosis is designated according to ____.
symptom, contrasting/comparative diagnoses, no additional code for symptom
When a symptom is followed by contrasting/comparative diagnoses, _____ is sequenced first. Codes are then assigned for _______. If the symptom, code is integral to each condition, ______ is assigned.
condition that occasioned admission
In a situation where the original treatment plan cannot be carried out due to unforseen circumstances, _____ is assigned.
Diagnoses that have no impact on patient care during the hospital stay are _____.
History and status codes may only be used as secondary codes if the historical condition or family history has an impact on _____.
query the physician, ask them to add necessary documentation
If a diagnosis is included in the final diagnostic statement, but there is no supporting documentation, the coder should _____ and ______.
Chronic conditions that affect patient care are coded even in the absence of documented intervention or evaluation because it almost always require some form of ______ or ______ during hospitalization.
Conditions that are an integral part of a disease process ______ be reported as additional diagnoses.
Condition that are not an integral part of a disease process _____ be coded when present.
This should be assigned only when the physician has not been able to arrive at a related diagnosis but indicates a clinically significant finding in the diagnostic statement.
abnormal findings alone
Coder should never assign a code on the basis of an ______.
principal diagnosis, complications, comorbidities, complications, procedures
Medicare reimbursement depends on the correct designation of _____, the presence or absence of additional codes that represent _____, _____, or major ______ as defined by Medicare, and _____ performed.
over coding, under reporting
_____ and _____ are unethical and may be considered fraudulent.
Failure to include all diagnoses or procedures that meet reporting criteria may result in _____ for the provider.
The source document for coding and reporting diagnoses and procedures is ___.
face sheet, final progress note, discharge summary
Discharge diagnoses are usually recorded on the ____, _____, or _____.
The _____ should be reviewed to determine the specific reason for the encounter and conditions treated.
approval of the physician
No diagnosis should be added without the ______
Review of record should begin with ____.
Code assignment is generally based on ______ documentation.
True or false. It is appropriate to assign a procedure code based on documentation by the nonphysician professional who provided the service.
YOU MIGHT ALSO LIKE...
NCLEX-RN Exam | Mometrix Comprehensive Guide
Uniform Hospital Discharge Data Set (UHDDS) Chap.4
Inpatient Coding Guidelines
Coding Guidelines- Chapter 3
OTHER SETS BY THIS CREATOR
Supervisory Management: Chaper 18 Sayles
Supervisory Management: Ch 29 - Future trends
Quality Management - Final Exam Review
Cancer Registry: Follow Up & Misc
THIS SET IS OFTEN IN FOLDERS WITH...
ICD9 Medical Coding: Ch 2 Procedures
ICD 9 Coding: Burns (Ch 17)
ICD 9 Coding: Poisoning and Adverse Effects (Ch 17)
ICD 9 Coding: Complication (Ch 17)