Coding

Front 1

What is UHDDS used for?

Back 1

reporting inpatient data in acute care, short tern care and long tern care

Front 2

What data item are required for the UHDDS?

Back 2

principal diagnosis,

other diagnoses that have significance for the hospital episode, and

all significance procedures

Front 3

What is the definition of principal diagnosis?

Back 3

the condition established after study to be chiefly responsible for admission of the patient to the hospital

Front 4

What is the importance of the correct principal diagnosis?

Back 4

cost comparisons, in care analysis, and in utilization review, reimbursement,

Front 5

What does third party payers including Medicare base their reimbursement on?

Back 5

principal diagnosis and it is crucial

Front 6

Where is the principal diagnosis listed in the physicians diagnostic statement?

Back 6

first

Front 7

What must a coder do to determine the condition that should be designated as the principal diagnosis?

Back 7

review the whole chart, the coder must look at everything

Front 8

What governs the selection of the principal diagnosis?

Back 8

the circumstances of the inpatient admission

Front 9

What takes precedence over all other guidelines for coding?

Back 9

Coding directives in the ICD-10-CM classification

Front 10

What is "after study"?

Back 10

the diagnosis found after workup or even surgery that proves to be the reason for admission.

Front 11

For a patient being admitted following medical observation what would the principal diagnosis be?

Back 11

report the medical condition that led to the hospital admission

Front 12

A patient undergoing outpatient surgery may require postoperative admission to an observation unit to monitor a condition that develops postoperative, how would a principal diagnosis be sought?

Back 12

"the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"

Front 13

Admission from Outpatient Surgery Guidelines

Back 13

*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 of 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

Front 14

What are the guidelines for Admissions/Encounters for Rehabilitation?

Back 14

Sequence first the code for the condition for which the service is being performed, * if the condition for which the rehabilitation servie is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis * don't code the stroke for rehab when admitted to rehab because the stroke is gone just the things that the stroke caused are left.

Front 15

When two or more diagnoses equally meet the criteria for principal diagnosis as determined bay the circumstances fo the admission and the diagnostic workup and /or therapy provided, either diagnosis may be sequenced first unless what?

Back 15

the Alphabetic Index or the Tabular List directs otherwise

Front 16

When should the condition be designated as the principal diagnosis?

Back 16

When treatment is totally or primarily directed toward one condition, or when only one condition would have required inpatient care.

Front 17

When no further determination can be made as to which diagnosis more closely meets the criteria for principal diagnosis how should it be coded?

Back 17

either diagnosis may be sequenced first

this does not apply to outpatient encounters

Front 18

When the original treatment plan cannot be carried out due to unforeseen circumstance, the criteria for designation of the principal diagnosis do not change?

Back 18

True

Front 19

When a planned treatment can not be carried out how is the principal diagnosis designated?

Back 19

The condition that occasioned the admission

Front 20

What is the definition of "other diagnosis" ?

Back 20

For UHDDS purposes it is only those conditions that affect the episode of hospital care in terms of, *clinical evaluation *therapeutic treatment *further evaluation by diagnostic studies, *procedures, *consultation, *extended length of stay, *increased nursing care and or other monitoring

Front 21

Should previous conditions stated as diagnosis be reported?

Back 21

No ==historical information or status post procedures performed on a previous admission that have no bearing on the current stay are not reported but may be used as secondary codes if the historical condition or family history has an impact on the current care or influences treatment.

Front 22

Ture or False

Other diagnosis with no documentation supporting reportability. Reporting of conditions for which there is no supporting documentation is in conflict with UHDDS criteria.

Back 22

True You can not code something that has no documentation for the physician

Front 23

What is the criteria for selection of chronic condition to be reported as "other diagnosis" include what?

Back 23

*the severity of the condition, *use or consideration of alternative measures, *increase in nursing care, *use of diagnostic or therapeutic services, *need for close monitoring, and *modifications of nursing care plans

Front 24

True or False

Conditions that are an integral part of a disease process should not be reported as additional diagnoses, unless otherwise instructed by the classification

Back 24

True

Front 25

True or False

Conditions that are NOT an integral part of a disease process should be coded when present.

Back 25

True (any thing that is not routinely associated with the disease are reported.)

Front 26

When should abnormal findings be listed?

Back 26

ONLY when the physician has not been able to arrive at a related diagnosis but indicated that the abnormal finding is considered to be clinically significant by listing it in the diagnostic statement

Front 27

True or False

Codes should never be assigned on the basis of an abnormal finding alone.

Back 27

True

Front 28

When should the physician be consulted about abnormal findings?

Back 28

When findings are clearly outside the normal range and the physician has ordered other test to evaluate the condition or has prescribed treatment without documenting as associated diagnosis ask physician whether a diagnosis should be added or whether the abnormal finding should be listed in the diagnostic statement. If something is found on an x-ray unless the physician list it it would not be coded. Must be documentation. If doctor don't talk about it it cannot be coded.

Front 29

Admitting Diagnosis

Back 29

*not an element of the UHDDS

*must be reported for some payers, *may be useful in quality-of-care studies,*only one admitting diagnosis can be reported

Front 30

Inpatient Admitting Diagnosis

Back 30

*a significant finding (symptom or sign) *possible diagnosis based on significant findings *diagnosis established on an ambulatory care basis or during a previous hospital admission *an injury or poisoning *a reason or condition not actually an illness or injury

Front 31

True or False

The UHDDS definition of principal diagnosis does not apply to outpatient encounters

Back 31

True

no after study element is involved because ambulatory care visits do not permit the continued evaluation ordinarily needed to meet UHDDS criteria

Front 32

If the physician does not identify a definite condition or problem at the conclusion of a visit or encounter how would this be coded?

Back 32

report the documented chief complaint as the reason for the visit/encounter

Front 33

Medicare reimbursement depends on what?

Back 33

*correct designation of the principal diagnosis *presence or absence of additional codes that represent complications, comorbidities, or major complications or comorbidities as defined by the MS-DRG system * procedures preformed

Front 34

In coding what would be considered fraudulent?

Back 34

over coding and over reporting (considered unethical)

Front 35

What standards should coders abide by?

Back 35

AHIMA Standards of Ethical Coding

Front 36

What steps should be taken to help providers resolve coding disputes with payers?

Back 36

*first determine whether it is really a coding dispute and not a coverage issue *contact payer for clarification if the reason for the denial is unclear *if a payer really does not have a policy that clearly conflicts with official coding rules or guidelines *if a payer refuses to provide its policy in writing document ass discussion with the payer *Keep a permanent record of the documentation obtained regarding payer coding policies