objective of the task ; To Evaluate assignment of diagnostic and procedural codes and groupings in accordance with official guidelines.
\nKnowledge Activity: UHDDS and the EHR<\/p>\n
Learning objectives
\n1.\tIdentify a complete health record according to organizational policies, external regulations, and standards (3)
\n2.\tCollect and maintain health data (2)
\n3.\tIdentify discrepancies between supporting documentation and coded data (3)
\n4.\tEvaluate processes, policies, and procedures to ensure the accuracy of coded data based on established guidelines (5)
\n5.\tImplement provider querying techniques to resolve coding discrepancies (3)
\nCAHIIM Competencies<\/p>\n
Domain V. Compliance
\nSubdomain V.B. Coding
\n1. Evaluate processes, policies, and procedures to ensure the accuracy of coded data based on established guidelines
\nSubdomain V.C. Fraud Surveillance
\n1.\tDetermine policies and procedures to monitor abuse or fraudulent trends.
\nSubdomain V.D. Clinical Documentation Improvement
\n1. Implement provider querying techniques to resolve coding discrepancies<\/p>\n
Student instructions
\n1.\tIf you have questions about this activity, please contact your instructor for assistance.
\n2.\tA 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.
\n3.\tRefer to the patient chart and any suggested resources to complete this activity.
\n4.\tDocument 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).<\/p>\n
Glossary
\nCMS (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\u2019s 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)
\nHospital identification: A number assigned to a patient for tracking purposes within a hospital. It can be the patient\u2019s 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)
\nICD (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)
\nPersonal identifier: A number assigned to a patient for tracking purposes within a hospital. It can be the patient\u2019s 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)
\nPhysician identification: Often identified as the \u201cunique 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)
\nPrincipal 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)
\nUHDDS: 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\u2019s episode of care, and financial information. (National Committee on Vital and Health Statistics (NCVHS), 1996)<\/p>\n
The activity
\nYou 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\u2019s EHR based on UHDDS guidelines.
\nThe 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.
\nQuestions
\nReview the de-identified patient under 2: Launch EHR to answer the questions below.
\nFor each numbered element listed below, additional information about that element may be included for reference. *Indicate the de-identified patient\u2019s 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\u2019s EHR. Elements that are not applicable to the patient will be listed with an N\/A.<\/p>\n
Person\/Enrollment Data:
\nThe 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.
\n*The following information can be found on the Registration section under the Account tab.
\nData 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.
\n1.\tWhat is the Personal\/Unique Identifier for this patient?<\/p>\n
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.
\n2.\tWhat is the Date of Birth for this patient?<\/p>\n
Data Element: Gender – As recommended by the UHDDS and the UACDS.
\n3.\tChoose the correct Gender option for this patient:
\na.\tMale
\nb.\tFemale
\nc.\tUnknown\/not stated
\nData 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:
\n4.\tRace\/Ethnicity \u2013 Choose the correct option for this patient:
\na.\tWhite or Caucasian
\nb.\tBlack or African American
\nc.\tHispanic
\nd.\tAsian
\ne.\tAmerican Indian
\nf.\tOther (specify)
\ng.\tUnknown\/not stated<\/p>\n
Data Element: Residence – Full address and ZIP code (nine-digit ZIP code, if available) of the individual’s usual residence.
\n5.\tWhat is the residence for this patient?<\/p>\n
Data Element: Marital Status – The following definitions, as recommended by the NCVHS, should be used.
\n6.\tChoose the correct Marital Status for this patient.
\na.\tMarried – A person currently married. Classify common law marriage as married.
\ni.\tMarried living together
\nii.\tMarried not living together
\niii.\tMarried living status unknown
\nb.\tNever married – A person who has never been married or whose only marriages have been annulled.
\nc.\tWidowed – A person widowed and not remarried.
\nd.\tDivorced – A person divorced and not remarried.
\ne.\tSeparated – A person legally separated.
\nf.\tUnknown\/not stated<\/p>\n
Data Element: Patient’s Relationship to Subscriber\/person eligible for entitlement \u2013 Person responsible for paying the bill for the encounter.
\n7.\tWhat is this patient\u2019s Relationship to Subscriber?
\na.\tSelf
\nb.\tSpouse
\nc.\tChild
\nd.\tOther (specify)<\/p>\n
Data Element: Living Arrangement.
\n8.\tChoose the correct Living Arrangement option for this patient.
\na.\tAlone
\nb.\tWith spouse
\nc.\tWith significant other\/life partner
\nd.\tWith children
\ne.\tWith parent or guardian
\nf.\tWith relatives other than spouse, children, or parents
\ng.\tWith non-relatives
\nh.\tUnknown\/not stated<\/p>\n
Data Element: Residential Arrangement.
\n9.\tChoose the correct Residential Arrangement option for this patient.
\na.\tOwn home or apartment
\nb.\tResidence where health, disability, or aging related services or supervision are available
\nc.\tOther residential setting where no services are provided
\nd.\tNursing home or other health facility
\ne.\tOther institutional setting (e.g. prison)
\nf.\tHomeless or homeless shelter
\ng.\tUnknown\/not stated<\/p>\n
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.
\n10.\tChoose the correct Self Reported Health Status option for this patient.
\na.\tExcellent
\nb.\tVery good
\nc.\tGood
\nd.\t Fair
\ne.\tPoor<\/p>\n
Data Element: Functional Status \u2013 No one standardized scale is recognized. The General Hospital uses the Instrumental Activities of Daily Living (IADL) scale results.
\n11.\tWhat is this patient\u2019s Functional Status?<\/p>\n
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.
\n12.\tWhat is this patient\u2019s Years of Schooling?<\/p>\n
Data Element: Current or Most Recent Occupation and Industry.
\n13.\tWhat is this patient\u2019s Current or Most Recent Occupation and Industry?
\nEncounter Data:
\nThe elements described in this section refer to information related to a specific health care encounter and are collected at the time of each encounter.
\nThe following information can be found on the Encounters section under the Account tab.
\nData Element: Type of Encounter – This element is critical to the placement of an encounter of care within its correct location.
\n14.\tChoose the correct Type of Encounter option for this patient.
\na.\tHospital inpatient
\nb.\tOutpatient
\nc.\tEmergency department
\nd.\tObservation
\ne.\tOther<\/p>\n
Data Element: Admission Date (inpatient)- Year, month, and day of admission.
\n15.\tWhat is this patient\u2019s Admission Date?<\/p>\n
Data Element: Discharge Date (inpatient) – Year, month, and day of discharge.
\n16.\tWhat is this patient\u2019s Discharge Date?<\/p>\n
Data Element: Facility Identification – The unique facility name and identifier number.
\n17.\tWhat is the Facility Identification for this patient?<\/p>\n
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.
\n18.\tWho is this patient\u2019s Attending Physician?<\/p>\n
Data Element: Disposition of Patient (inpatient).
\n19.\tChoose the correct Disposition of Patient for this patient.
\na.\tDischarged Alive options:
\ni.\tDischarged to home or self-care (routine discharge)
\nii.\tDischarged\/transferred to another short term general hospital for inpatient care
\niii.\tDischarged\/transferred to skilled nursing facility (SNF)
\niv.\tDischarged\/transferred to an intermediate care facility (ICF)
\nv.\tDischarged\/transferred to another type of institution for inpatient care or referred for outpatient services to another institution
\nvi.\tDischarged\/transferred to home under care of organized home health service organization
\nvii.\tDischarged\/transferred to home under care of a Home IV provider
\nviii.\tLeft against medical advice or discontinued care
\nb.\tExpired
\nc.\tStatus not stated
\nData Element: N\/A: Health Care Practitioner Identification (outpatient) – The unique national identification number assigned to the health care practitioner of record for each encounter.
\nData 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
\nThe following information can be found on the Problems Tab under Health.
\nData 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.
\n20.\tWhat is this patient\u2019s Principal Diagnosis?<\/p>\n
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.
\n21.\tWhat is this patient\u2019s Primary Diagnosis?<\/p>\n
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.\u201d Onset prior to admission: Yes\/No.
\n22.\tWhat is this patient\u2019s Other Diagnoses? Indicate whether onset prior to admission.
\nData 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.
\nData Element: N\/A: Birth Weight of Newborn (inpatient) – The specific birth weight of the newborn, recorded in grams.
\nThe following information can be found on the Claims section in the Accounts tab.
\nProcedures (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.
\nData 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.
\n23.\tWhat is this patient\u2019s Principal Procedure?
\nData Element: N\/A: Other Procedures (inpatient) – All other procedures that meet the criteria.
\nData Element: Dates of Procedures (inpatient) – Year, month, and day, as recommended in the UHDDS and by ANSI ASC X12, of each significant procedure.
\n24.\tWhat is this patient\u2019s Dates of Procedure?
\nThe following information can be found on the Meds Tab in the Health section. Click into active medication orders to view the details.
\nData 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.
\n25.\tWhat are this patient\u2019s Medications Prescribed?
\nThe following information can be found on the Insurance section in the Accounts tab.
\nData 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.
\n26.\tWhat is this patient\u2019s Expected Sources of Payment?<\/p>\n
Data Element: Secondary Source – The secondary source, if any, that will be responsible for the next largest percentage of the patient’s current bill.
\n27.\tWhat is this patient\u2019s Secondary Source?<\/p>\n
Data Element: Injury Related to Employment \u2013 Yes\/No.
\n28.\tIs this patient\u2019s injury related to employment?
\nThe following information can be found on the Claims and Ledger sections in the Accounts tab.
\nData Element: Total Billed Charges – All charges for procedures and services rendered to the patient during a hospitalization or encounter.
\n29.\tWhat is this patient\u2019s Total Billed Charges?
\nCritical Thinking Questions
\n30.\tBased on your knowledge of billing and reimbursement, why is selection of the correct principal diagnosis so critical?<\/p>\n
31.\tThe 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?
\nSubmit your work
\nDocument 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.
\nReferences
\nCenters for Medicare and Medicaid Services. (2018, May 29). We’re putting patients first. Retrieved from CMS.Gov: https:\/\/www.cms.gov\/
\nCMS, 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
\nNational Committee on Vital and Health Statistics (NCVHS). (1996). Preliminary Recommondations for Core Health Data Elements. D.C.: NCVHS.
\nWorld Health Organization. (2018, May 29). Classifications. Retrieved from WHO.INT: http:\/\/www.who.int\/classifications\/icd\/en\/<\/p>\n","protected":false},"excerpt":{"rendered":"
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