There are three uploaded documents. The first two are just information to look back on to answer the questions. The last uploaded document that says:   EHRGo Assignment: UHHDS and the EHR is actual question sheet. There are 31 questions. 

Principal Diagnosis/

First Listed Diagnosis

ICD-10-CM

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Let’s go back to basics as we prepare for the implementation of ICD-10-CM and review the Guidelines for designation of the
Principal Diagnosis for inpatient use and First Listed Diagnosis for outpatient use.

Principal Diagnosis

The definition of the Principal Diagnosis as defined in the Uniform Hospital discharge Data Set (UHDDS): “That condition
established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Why is it important to make the correct selection of the Principal Diagnosis?
• It is significant in cost comparisons, in care analysis, and in utilization review.
• It is crucial for reimbursement because many third-party payers (including Medicare) base reimbursement primarily
on principal diagnosis.

The principal diagnosis is not necessarily the same diagnosis as the admitting diagnosis, but it is the diagnosis found after
workup, or even after surgery, that is determined to be the reason for admission.

The principal diagnosis may, or may not, be listed first in the physician’s diagnostic statement, but sequencing in the
diagnostic statement or discharge summary cannot be the determining factor in establishing the Principal Diagnosis. Always
review the entire medical record to determine the condition that should be designated as the principal diagnosis.

A review of the ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 to reestablish our knowledge of the
Principal Diagnosis is always helpful. The guidelines may be downloaded at:

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-10-CM-Guidelines

ICD-10-CM Official Guidelines for Coding and Reporting FY 2016

Section II. Selection of Principal Diagnosis

A. Codes for symptoms, signs, and ill-defined conditions

Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive

diagnosis has been established.

B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis.
When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter or manifestations

characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be

sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate

otherwise.

C. Two or more diagnoses that equally meet the definition for principal diagnosis
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the

circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding

guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced

first.

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D. Two or more comparative or contrasting conditions
In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar

terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of

the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced

first.

E. A symptom(s) followed by contrasting/comparative diagnoses
GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014

F. Original treatment plan not carried out
Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment

may not have been carried out due to unforeseen circumstances.

G. Complications of surgery and other medical care
When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is

sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary

specificity in describing the complication, an additional code for the specific complication should be assigned.

H. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or

“still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases

for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that

correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

I. Admission from Observation Unit
1. Admission Following Medical Observation
When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is

subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be

the medical condition which led to the hospital admission.

2. Admission Following Post-Operative Observation
When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following

outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform

Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as “that condition established after study to be chiefly

responsible for occasioning the admission of the patient to the hospital for care.”

J. Admission from Outpatient Surgery
When a patient receives surgery in the hospital’s outpatient surgery department and is subsequently admitted for continuing inpatient

care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission:

• If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.

• If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the

outpatient surgery as the principal diagnosis.

• If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as

the principal diagnosis.

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K. Admissions/Encounters for Rehabilitation
When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is

being performed. For example, for an admission/encounter 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, as the first-listed or principal diagnosis.

If the condition for which the rehabilitation service is no longer present, report the appropriate aftercare code as the first-listed or

principal diagnosis. For example, if a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the

current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the first-listed

or principal diagnosis.

First Listed Diagnosis

The first thing to keep in mind when coding outpatient cases is that the UHDDS definition of principal diagnosis does not
apply to outpatient encounters.

In contrast to inpatient coding, there is no “after study” component involved in the selection of the First Listed Diagnosis
because ambulatory care visits do not permit the continued evaluation ordinarily needed to meet UHDDS criteria.

If the physician does not identify a definite condition or problem at the conclusion of a visit or encounter, report the
documented chief complaint as the reason for the encounter/visit.

And now a review of the ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 to reestablish our knowledge of
the First Listed Diagnosis.

ICD-10-CM Official Guidelines for Coding and Reporting FY 2016

Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services

A. Selection of first-listed condition

In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.

In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence

over the outpatient guidelines.

Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.

The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in

the Tabular List as this will lead to coding errors.

1. Outpatient Surgery

When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason

for the encounter), even if the surgery is not performed due to a contraindication.

2. Observation Stay

When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis.

When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the

surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses.

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G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit

List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly

responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a

symptom when a diagnosis has not been established (confirmed) by the physician.

H. Uncertain diagnosis

Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating

uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results,

or other reason for the visit.

Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

K. Patients receiving diagnostic services only

For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for

encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other

diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.

For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for

other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it

is appropriate to assign both the Z code and the code describing the reason for the non-routine test.

For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code

any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.

L. Patients receiving therapeutic services only

For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for

encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other
diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.

The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z

code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

M. Patients receiving preoperative evaluations only

For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to

describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any

findings related to the pre-op evaluation.

N. Ambulatory surgery

For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the

preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

O. Routine outpatient prenatal visits

See Section I.C.15. Routine outpatient prenatal visits.

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P. Encounters for general medical examinations with abnormal findings

The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general

medical examination result in an abnormal finding, the code for general medical examination with abnormal finding should be assigned as the

first-listed diagnosis. A secondary code for the abnormal finding should also be coded.

Q. Encounters for routine health screenings

See Section I.C.21. Factors influencing health status and contact with health services, Screening

September 17, 2015
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Uniform Hospital Discharge Data Set –

UHDDS
P o sted o n July 2 5 , 2 0 1 5

Medical Billing Coding World

Implemented in 1974, the Uniform Hospital Discharge Data Set (UHDDS) was originally an initiative by

the predecessor of today’s Department of Health and Human Services (HHS), the Department of Health,

Education, and Welfare.

The creation of the UHDDS is indirectly a result of the founding of the Medicare program in 1965. As the

federal government was becoming increasingly involved in healthcare, analysts realized the importance

of creating a standardized system of medical coding that would allow for an easier comparison between

hospitals.

Having comparable data could help to determine which hospitals were best at treating patients, which

could in turn serve as models to lower costs for the government saved from patients who were not

repeatedly readmitted. This data could also be used to compare the reimbursement rates of different

hospitals for similar medical procedures, and thereby work towards a standardized system of

reimbursement for the federal government nationwide. Until this point prices could vary greatly from

region to region, and even between hospitals in the same city, because there was not a national

reimbursement system in place.

Standardization in reimbursement rates also helped hospitals move towards standardization in quality

of care. This provided a measuring stick for under-performing hospitals offering sub-standard levels of

care, and once these facilities were identified measures could be taken to improve them. While the

importance of this is inherently obvious, remember that when Medicare was created in 1965

segregation was still rampant in the United States – all the more reason to use data to compel hospitals

to provide equal levels of care.

UHDDS Today

Since its implementation in 1974 the UHDDS has undergone several revisions. While this information is

specific to hospitals that provide medical services for those covered by Medicare and Medicaid, it has

become standard practice for all insurance companies to gather information similar to the UHDDS

because of the recognized value of having comparable data. Medical billing and coding professionals will

recognize the following information as being required on today’s UHDDS forms:

• Hospital or facility identification number or code

• Expected insurance payer number or code

• Sex, age, and race of the patient

• Significant medical procedures performed

• Principal diagnosis

• Additional significant diagnoses

Today in addition to hospitals, facilities such as the following might use the UHDDS:

• Rehabilitation facilities

• Nursing and retirement communities

• Home health care providers

Medical billing and coding professionals who work in these types of facilities with Medicare and

Medicaid recipients should become adept at filing the UHDDS. This can affect the overall rate of

reimbursement, so coding correctly can improve a medical service provider’s bottom line. Some points

that may prove to be tricky include:

• The inclusion of other diagnoses – only other diagnoses that are part of the immediate health

care services provided should be reported

• Order of other diagnoses – when reporting these, it can be important to list the most serious

diagnoses first, especially if there is a limit on the amount that may be listed

• Inclusion of previous diagnoses – even if these are reported in a medical record by a doctor,

billing and coding professionals should not report these on the UHDDS if they do not have a

bearing on the current medical services performed

• Inclusion of chronic conditions – even if chronic conditions are not part of the immediate

medical services provided, they should be reported because they must be constantly monitored

and evaluated

https://medicalbillingcodingworld.com/2015/07/uniform-hospital-discharge-data-set-uhdds/

Glossary

CMS (Centers for Medicare and Medicaid Services): An agency of the U.S. Department of Health and Human Services responsible for administration of several key federal health care programs. In addition to Medicare (the federal health insurance program for seniors) and Medicaid (the federal needs-based program), CMS oversees the Children’s Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act (HIPAA) and the Clinical Laboratory Improvement Amendments (CLIA), among other services. (Centers for Medicare and Medicaid Services, 2018)

Hospital identification: A number assigned to a patient for tracking purposes within a hospital. It can be the patient’s Medicare or Medicaid number, their social security number, or a random number assigned by the facility. (National Committee on Vital and Health Statistics (NCVHS), 1996)

ICD (International Classification of Diseases): The standard diagnostic tool for epidemiology, health management and clinical purposes. This includes the analysis of the general health situation of population groups. It is used to monitor the incidence and prevalence of diseases and other health problems. (World Health Organization, 2018)

Personal identifier: A number assigned to a patient for tracking purposes within a hospital. It can be the patient’s Medicare or Medicaid number, their social security number, or a random number assigned by the facility. (National Committee on Vital and Health Statistics (NCVHS), 1996)

Physician identification: Often identified as the “unique physician identification number (UPIN). NPI (National Provider Numbers) are more often used in place of the UPIN. NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). (CMS, 2012)

Principal Diagnosis: The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. (National Committee on Vital and Health Statistics (NCVHS), 1996)

UHDDS: The Uniform Hospital Discharge Data Set (UHDDS) is a common core of data. The goal of the UHDDS data is to obtain uniform comparable discharge data on all inpatients. This set of data provides a minimum description of a hospital admission. Data elements can be categorized into patient identification, provider information, clinical information of the patient’s episode of care, and financial information. (National Committee on Vital and Health Statistics (NCVHS), 1996)

The activity

You are a student from a local Health Information Technology program. You are on a Directed Practice at a large hospital in your area. When you arrive, the Health Information Director places you with an inpatient coder who has over fifteen years of experience. You are only at the hospital for one day. Your objective for the day is to better understand how coding and the UHDDS relate to one another. The coder tells you that she will have you begin with abstracting data from an inpatient medical chart in the hospital’s EHR based on UHDDS guidelines.

The Director provides you with the Core Health Data Elements below, each of which fall under one of these categories: Person/Enrollment Data and Encounter Data.

Questions

Review the de-identified patient under 2: Launch EHR to answer the questions below.

For each numbered element listed below, additional information about that element may be included for reference. *Indicate the de-identified patient’s relevant information regarding the given element or, when provided with multiple options, choose the best option for the de-identified patient based on the information in the patient’s EHR. Elements that are not applicable to the patient will be listed with an N/A.

Person/Enrollment Data:

The elements described in this section refer to information collected on enrollment or at an initial visit to a health care provider or institution. It is anticipated that these elements will be collected on a one-time basis or updated on an annual basis. Except for the personal/unique identifier, they do not need to be collected at each encounter.

*The following information can be found on the Registration section under the Account tab.

Data Element: Personal/Unique Identifier – The unique name or numeric identifier that will set apart information for an individual person for research and administrative purposes. In the General Hospital, this is the MR# for the patient.

1. What is the Personal/Unique Identifier for this patient?

Data Element: Date of Birth – Year, month and day – As recommended by the UHDDS and the Uniform Ambulatory Care Data Set (UACDS). It is recommended that the year of birth be recorded in four digits to make the data element more reliable for the increasing number of persons of 100 years and older. It will also serve as a quality check as the date of birth approaches the new century mark.

2. What is the Date of Birth for this patient?

Data Element: Gender – As recommended by the UHDDS and the UACDS.

3. Choose the correct Gender option for this patient:

a. Male

b. Female

c. Unknown/not stated

Data Element: Race and Ethnicity – The collection of race and ethnicity have been recommended by the UHDDS and the UACDS, and these elements have a required definition for Federal data collection in Office of Management and Budget (OMB) Directive 15. The definition has been expanded slightly from the OMB requirement:

4. Race/Ethnicity – Choose the correct option for this patient:

a. White or Caucasian

b. Black or African American

c. Hispanic

d. Asian

e. American Indian

f. Other (specify)

g. Unknown/not stated

Data Element: Residence – Full address and ZIP code (nine-digit ZIP code, if available) of the individual’s usual residence.

5. What is the residence for this patient?

Data Element: Marital Status – The following definitions, as recommended by the NCVHS, should be used. **In addition to the Account/Registration section of the chart, also refer to the patient’s notes on the Notes tab (under the Health section) to determine the best answer.

6. Choose the correct Marital Status for this patient.

a. Married – A person currently married. Classify common law marriage as married.

i. Married living together

ii. Married not living together

iii. Married living status unknown

b. Never married – A person who has never been married or whose only marriages have been annulled.

c. Widowed – A person widowed and not remarried.

d. Divorced – A person divorced and not remarried.

e. Separated – A person legally separated.

f. Unknown/not stated

Data Element: Patient’s Relationship to Subscriber/person eligible for entitlement – Person responsible for paying the bill for the encounter.

7. What is this patient’s Relationship to Subscriber?

a. Self

b. Spouse

c. Child

d. Other (specify)

Data Element: Living Arrangement.

8. Choose the correct Living Arrangement option for this patient.

a. Alone

b. With spouse

c. With significant other/life partner

d. With children

e. With parent or guardian

f. With relatives other than spouse, children, or parents

g. With non-relatives

h. Unknown/not stated

Data Element: Residential Arrangement.

9. Choose the correct Residential Arrangement option for this patient.

a. Own home or apartment

b. Residence where health, disability, or aging related services or supervision are available

c. Other residential setting where no services are provided

d. Nursing home or other health facility

e. Other

institutional setting (e.g. prison)

f. Homeless or homeless shelter

g. Unknown/not stated

*The following information can be found on the Notes section under the Health tab.

Data Element: Self-Reported Health Status – A commonly used measure is the person’s rating of his or her own general health in the five-category classification.

10. Choose the correct Self Reported Health Status option for this patient.

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

Data Element: Functional Status – No one standardized scale is recognized. The General Hospital uses the Instrumental Activities of Daily Living (IADL) scale results.

11. What is this patient’s Functional Status?

Data Element: Years of Schooling – Highest grade of schooling completed by the enrollee/patient. For children under the age of 18, the mother’s highest grade of schooling completed should be obtained.

12. What is this patient’s Years of Schooling?

Data Element: Current or Most Recent Occupation and Industry.

13. What is this patient’s Current or Most Recent Occupation and Industry?

Encounter Data:

The elements described in this section refer to information related to a specific health care encounter and are collected at the time of each encounter.

*The following information can be found on the Encounters section under the Account tab.

Data Element: Type of Encounter – This element is critical to the placement of an encounter of care within its correct location.

14. Choose the correct Type of Encounter option for this patient.

a. Hospital inpatient

b. Outpatient

c. Emergency department

d. Observation

e. Other

Data Element: Admission Date (inpatient)- Year, month, and day of admission.

15. What is this patient’s Admission Date?

Data Element: Discharge Date (inpatient) – Year, month, and day of discharge.

16. What is this patient’s Discharge Date?

Data Element: Facility Identification – The unique facility name and identifier number.

17. What is the Facility Identification for this patient?

Data Element: Attending Physician Identification (inpatient) – The unique national identification number assigned to the clinician of record at discharge who is responsible for the discharge summary.

18. Who is this patient’s Attending Physician?

Data Element: Disposition of Patient (inpatient).

19. Choose the correct Disposition of Patient for this patient.

a. Discharged Alive options:

i. Discharged to home or self-care (routine discharge)

ii. Discharged/transferred to another short term general hospital for inpatient care

iii. Discharged/transferred to skilled nursing facility (SNF)

iv. Discharged/transferred to an intermediate care facility (ICF)

v. Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution

vi. Discharged/transferred to home under care of organized home health service organization

vii. Discharged/transferred to home under care of a Home IV provider

viii. Left against medical advice or discontinued care

b. Expired

c. Status not stated

Data Element: N/A: Health Care Practitioner Identification (outpatient) – The unique national identification number assigned to the health care practitioner of record for each encounter.

Data Element: N/A: Location or Address of Encounter (outpatient) – The full address and Zip Code (nine digits preferred) for the location at which care was received from the health care practitioner of record

*The following information can be found on the Problems Tab under Health.

Data Element: Principal Diagnosis (inpatient) – As recommended by the UHDDS, the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital or nursing home for care. The currently recommended coding instrument is the ICD-10.

20. What is this patient’s Principal Diagnosis?

Data Element: Primary Diagnosis (inpatient) – The diagnosis that is responsible for the majority of the care given to the patient or resources used in the care of the patient. The currently recommended coding instrument is the ICD-10.

21. What is this patient’s Primary Diagnosis?

Data Element: Other Diagnoses (inpatient) – As recommended by the UHDDS, all conditions that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay. Diagnoses that refer to an earlier episode that have no bearing on the current hospital or nursing home stay are to be excluded. Conditions should be coded that affect patient care in terms of requiring clinical evaluation; therapeutic treatment; diagnostic procedures; extended length of hospital or nursing home stay; or increased nursing care and/or monitoring. The following qualifier should be applied to each diagnosis coded under “other diagnoses.” Onset prior to admission: Yes/No.

22. What is this patient’s Other Diagnoses? Indicate whether onset prior to admission.

Data Element: N/A: External Cause of Injury – This item should be completed whenever there is a diagnosis of an injury, poisoning, or adverse effect. The currently recommended coding instrument is the ICD- 10. The priorities for recording an External Cause-of-Injury code (E-code) are: Principal diagnosis of an injury or poisoning; Other diagnosis of an injury, poisoning, or adverse effect directly related to the principal diagnosis; Other diagnosis with an external cause.

Data Element: N/A: Birth Weight of Newborn (inpatient) – The specific birth weight of the newborn, recorded in grams.

*The following information can be found on the Claims section in the Accounts tab.

Procedures (inpatient) – All significant procedures, and dates performed, are to be reported. A significant procedure is one that is: Surgical in nature, or Carries a procedural risk, or Carries an anesthetic risk, or Requires specialized training. Surgery includes incision, excision, amputation, introduction, endoscopy, repair, destruction, suture, and manipulation. A qualifier element is recommended to indicate the type of coding structure used, i.e., ICD, CPT, etc.

Data Element: Principal Procedure (inpatient)- As recommended by the UHDDS, 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 are principal, then the one most related to the principal diagnosis should be selected as the principal procedure.

23. What is this patient’s Principal Procedure?

Data Element: N/A: Other Procedures (inpatient) – All other procedures that meet the criteria.

*The following information can be found on the Notes Tab in the Health section.

Data Element: Dates of Procedures (inpatient) – Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure.

24. What is this patient’s Date(s) of Procedure?

*The following information can be found on the Meds Tab in the Health section. Click into active medication orders to view the details.

Data Element: Medications Prescribed – Describe all medications prescribed or provided by the health care practitioner at the encounter (for outpatients) or given on discharge to the patient (for inpatients), including, where possible, National Drug Code (aka barcode number), dosage, strength, and total amount prescribed.

25. What are this patient’s Medications Prescribed?

*The following information can be found on the Insurance section in the Accounts tab.

Data Element: Patient’s Expected Sources of Payment – Primary Source – The primary source that is expected to be responsible for the largest percentage of the patient’s current bill. Include the insurance company name and member ID.

26. What is this patient’s Expected Sources of Payment?

Data Element: Secondary Source – The secondary source, if any, that will be responsible for the next largest percentage of the patient’s current bill.

27. What is this patient’s Secondary Source?

Data Element: Injury Related to Employment – Yes/No.

28. Is this patient’s injury related to employment?

*The following information can be found on the Claims and Ledger sections in the Accounts tab.

Data Element: Total Billed Charges – All charges for procedures and services rendered to the patient during a hospitalization or encounter.

29. What is this patient’s Total Billed Charges?

Critical Thinking Questions

30. Based on your knowledge of billing and reimbursement, why is selection of the correct principal diagnosis so critical?

31. The UHDDS is utilized by hospitals that treat and bill for Medicare and Medicaid patients. Why do you think CMS (Centers for Medicare and Medicaid Services) utilizes a data set? What process(es) does this improve for CMS?