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The UHDDS definitions are used by acute care hospitals to report inpatient data elements in a standardized manner. The UHDDS data elements used in the DRG classification system are described below. Proper DRG assignment and resulting reimbursement is dependent on reporting these elements correctly.
Diagnoses: All diagnoses that affect the current hospital stay are to be reported.
Principal diagnosis is defined as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."
Other (Additional) diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay."
Diagnoses that are related to an earlier episode of care, which have no bearing on the current hospital stay, are to be excluded. For reporting purposes the definition for 'other diagnoses' is interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation; therapeutic treatment; diagnostic procedures; extended length of hospital stay; or increased nursing care and/or monitoring.
Procedures: All significant procedures are to be reported. Significant procedures are those that are surgical in nature; carry a procedural risk; carry an anesthetic risk; or require specialized training.
The principal procedure is one that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. If there appear to be two procedures that meet the above definition, then the one most related to the principal diagnosis should be selected as the principal procedure.
Under IPPS all procedures potentially affecting payment must be reported.
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