objective of the task ; To Evaluate assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.
Knowledge Activity: UHDDS and the EHR
1. Identify a complete health record according to organizational policies, external regulations, and standards (3)
2. Collect and maintain health data (2)
3. Identify discrepancies between supporting documentation and coded data (3)
4. Evaluate processes, policies, and procedures to ensure the accuracy of coded data based on established guidelines (5)
5. Implement provider querying techniques to resolve coding discrepancies (3)
Domain V. Compliance
Subdomain V.B. Coding
1. Evaluate processes, policies, and procedures to ensure the accuracy of coded data based on established guidelines
Subdomain V.C. Fraud Surveillance
1. Determine policies and procedures to monitor abuse or fraudulent trends.
Subdomain V.D. Clinical Documentation Improvement
1. Implement provider querying techniques to resolve coding discrepancies
1. If you have questions about this activity, please contact your instructor for assistance.
2. A de-identified patient chart will be used to complete this activity. Your instructor has provided you with a link to the UHDDS and the EHR (BS) activity. Click on 2: Launch EHR to review the patient chart and begin this activity.
3. Refer to the patient chart and any suggested resources to complete this activity.
4. Document your answers directly on this activity document as you complete the activity. When you are finished, you will save this activity document to your device and upload this activity document with your answers to your Learning Management System (LMS).
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)
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.
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.
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:
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
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.
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?
d. Other (specify)
Data Element: Living Arrangement.
8. Choose the correct Living Arrangement option for this patient.
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
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.
b. Very good
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?
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
c. Emergency department
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
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.
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 Dates 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?
Submit your work
Document your answers directly on this activity document as you complete the activity. When you are finished, save this activity document to your device and upload this activity document with your answers to your Learning Management System (LMS). If you have any questions about submitting your work to your LMS, please contact your instructor.
Centers for Medicare and Medicaid Services. (2018, May 29). We’re putting patients first. Retrieved from CMS.Gov: https://www.cms.gov/
CMS, S. G. (2012, June 11). Unique Physician Identification Numbers (UPINs) and Associated Files. Retrieved from Research Data Assistance Center: https://www.resdac.org/resconnect/articles/133
National Committee on Vital and Health Statistics (NCVHS). (1996). Preliminary Recommondations for Core Health Data Elements. D.C.: NCVHS.
World Health Organization. (2018, May 29). Classifications. Retrieved from WHO.INT: http://www.who.int/classifications/icd/en/