Uniform Hospital Discharge Data Set

CHAPTER OVERVIEW
 
 The Uniform Hospital Discharge Data Set (UHDDS) is used for
reporting inpatient data.
 The following items are always found in the UHDDS:

-- General demographic information

-- Expected payer

-- Hospital identification

-- Principal diagnosis

-- Other diagnoses that have specific significance

-- All significant procedures

 The rules for identifying the first-listed diagnosis for an outpatient
encounter differ from those for selecting the principal diagnosis for an
inpatient encounter.
 Following all the coding guidelines will ensure accurate and ethical
coding.

LEARNING OUTCOMES
 
After studying this chapter you should be able to:
 
 Correctly identify a principal diagnosis.
 Understand the guidelines for assigning a principal diagnosis.
 Understand when other diagnoses have significance and should be
reported.
 Explain the difference between a principal diagnosis and an admitting
diagnosis.
 Explain the importance of accurate and ethical coding.

TERMS TO KNOW
 
MS-DRG system
Medicare severity-adjusted diagnosis-related groups system; a patient classification
system used in hospital inpatient reimbursement
 
Other reportable diagnoses
conditions that coexist at the time of admission, develop subsequently, or affect
patient care during the hospital stay
 
Principal diagnosis
the condition established after study that is chiefly responsible for admission of the
patient to the hospital
 
UHDDS
Uniform Hospital Discharge Data Set; information used for reporting inpatient data

REMEMBER
 
The admitting diagnosis is not an element of the UHDDS.
. . . Diagnoses that have no impact on patient care or that are related to an earlier
episode are not reported on the UHDDS.

INTRODUCTION
 
The Uniform Hospital Discharge Data Set (UHDDS) is used for reporting inpatient
data in acute care, short-term care, and long-term care hospitals. It uses a minimum
set of items based on standard definitions that could provide consistent data for
multiple users. Only those items that met the following criteria were included:
 
 Easily identified
 Readily defined
 Uniformly recorded
 Easily abstracted from the medical record

Its use is required for claims reporting for Medicare and Medicaid patients. In
addition, many other health care payers use most of the UHDDS as a uniform billing
system.

DATA ITEMS
 
The UHDDS requires the following items:
 
 Principal diagnosis
 Other diagnoses that have significance for the specific hospital episode
 All significant procedures

The four cooperating parties responsible for developing and maintaining ICD-10-CM
(American Hospital Association, American Health Information Management
Association, Centers for Medicare & Medicaid Services, and Centers for Disease
Control and Prevention's National Center for Health Statistics) have developed
official guidelines for designating the principal diagnosis and for identifying other
diagnoses that should be reported in certain situations. The UHDDS also contains a
core of general information that pertains to the patient and to the specific episode of
care, such as the age, sex, and race of the patient; the expected payer; and the
hospital's identification.
     The UHDDS definitions were originally developed in 1985 for hospital reporting
of inpatient data elements. Since that time, the application of UHDDS definitions has
been expanded to include all nonoutpatient settings. In addition to their application to
acute care, short-term care, and long-term care hospitals, the definitions for principal
diagnosis and other (secondary) diagnoses also apply to psychiatric hospitals, home
health agencies, rehabilitation facilities, nursing homes, hospice, and other settings.
Guidelines for selection of principal diagnosis and other diagnoses discussed below
apply to all these settings. Please note that the guideline regarding coding of uncertain
(unconfirmed) diagnosis (a diagnosis documented at the time of discharge as
"probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out,"
or another similar term indicating uncertainty) as if the condition existed or were
established is an exception. The guideline regarding uncertain diagnosis applies only
to inpatient admissions to acute care, short-term care, long-term care, and psychiatric
hospitals. Coding of uncertain (unconfirmed) diagnoses is discussed in more detail
in chapter 7 of this handbook.

Principal Diagnosis
 
     The principal diagnosis is defined as the condition established after study to be
chiefly responsible for admission of the patient to the hospital for care. It is important
that the principal diagnosis be designated correctly because its establishment is
significant in cost comparisons, in care analysis, and in utilization review. Accurate
designation of the principal diagnosis is crucial for reimbursement because many
third-party payers (including Medicare) base reimbursement primarily on principal
diagnosis. The principal diagnosis is ordinarily listed first in the physician's diagnostic
statement, but not always; the entire medical record must be reviewed to determine
the condition that should be designated as the principal diagnosis.
     The words "after study" in the definition of principal diagnosis are important, but
their meaning is sometimes confusing. It is not the admitting diagnosis but rather the
diagnosis found after workup or even after surgery that proves to be the reason for
admission. For example:
 
 A patient admitted with urinary retention may prove to have
hypertrophy of the prostate, which is causing the urinary retention. In this
case, the prostatic hypertrophy is the principal diagnosis unless treatment was
directed only to the urinary retention.
 A patient is admitted because of chronic cough, difficulty with
breathing, and malaise; a bronchoscopy with biopsy is performed for a lung
mass. The mass is confirmed to be adenocarcinoma of the lung. In this case,
the lung adenocarcinoma is the principal diagnosis because, after study, it was
determined to be the underlying cause of the patient's malaise and respiratory
symptoms as well as the reason for admission.
 A patient is admitted with severe abdominal pain. The white blood cell
count is elevated to 16,000, with shift to the left. The patient is taken to
surgery, where an acute ruptured appendix is removed. After study, the
principal diagnosis is determined to be acute ruptured appendicitis.
 A patient is admitted with severe abdominal pain in the right lower
quadrant, and an admitting diagnosis of probable acute appendicitis is given.
The white blood cell count is slightly elevated. The patient is taken to surgery,
where a normal appendix is found but an inflamed Meckel's diverticulum is
removed. After study, the principal diagnosis is determined to be Meckel's
diverticulum.

     The circumstances of inpatient admission always govern the selection of the

principal diagnosis, and the coding directives in the ICD-10-CM classification take
precedence over all other guidelines. The importance of consistent, complete
documentation in the medical record cannot be overemphasized. Without such
documentation, the application of all coding guidelines is a difficult, if not impossible,
task.
     There are special instructions related to the selection of principal diagnosis when a
patient is admitted as an inpatient from the hospital's observation unit or from
outpatient surgery. The coding advice provided below applies if a single bill is
submitted to a payer. If separate inpatient and outpatient bills are submitted, then the
advice does not apply. Hospitals should apply codes for the current encounter based
on individual payer billing instructions.
     For example:
 
 Admission following medical observation: A patient may be treated in
a hospital's observation unit to determine whether the condition improves
sufficiently for the patient to be discharged. If the condition either worsens or
does not improve, the physician may decide to admit the patient as an inpatient
of the same hospital for this same medical condition. The principal diagnosis
reported is the medical condition that led to the hospital admission.
 Admission following postoperative observation: A patient undergoing
outpatient surgery may require postoperative admission to an observation unit
to monitor a condition (or complication) that develops postoperatively. If the
patient subsequently requires inpatient admission to the same hospital, the
UHDDS definition of principal diagnosis applies: "that condition established
after study to be chiefly responsible for occasioning the admission of the
patient to the hospital for care."
 Admission from outpatient surgery: A patient undergoing outpatient
surgery may be 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.
 Admissions/encounters for rehabilitation: A patient may require
inpatient or outpatient rehabilitation services. The following guidelines should
be followed for the selection of the principal diagnosis or first-listed diagnosis
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 was required is no longer
present, report the appropriate aftercare code -- or report the traumatic injury
 with the appropriate seventh character for subsequent encounter -- as the first-
listed or principal diagnosis.

  Example If a patient with severe degenerative osteoarthritis of the hip underwent

1: hip replacement, and the current encounter/admission is required for
rehabilitation, report code Z47.1, Aftercare following joint replacement
surgery, as the first-listed or principal diagnosis.
  Example If the patient requires rehabilitation post hip replacement for right
2: intertrochanteric femur fracture, report code S72.141D, Displaced
intertrochanteric fracture of right femur, subsequent encounter for
closed fracture with routine healing, as the first-listed or principal
diagnosis.
 
     The following official guidelines for designating the principal diagnosis apply to
all systems and etiologies. (Guidelines that apply only to specific body systems or
etiologies are discussed in the relevant chapters of this handbook. To download a
copy of the current version of the complete ICD- 10-CM Official Guidelines for
Coding and Reporting, please visit www.ahacentraloffice.org.)
 
1. Two or more diagnoses that equally meet the definition for principal diagnosis: In the
unusual situation that two or more diagnoses equally meet the criteria for principal
diagnosis as determined by the circumstances of the admission and the diagnostic
workup and/or therapy provided, either may be sequenced first when neither the
Alphabetic Index nor the Tabular List directs otherwise. However, it is not simply the
fact that both conditions exist that makes this choice possible. When treatment is
totally or primarily directed toward one condition, or when only one condition would
have required inpatient care, that condition should be designated as the principal
diagnosis. Also, if another coding guideline (general or disease specific) provides
sequencing direction, that guideline must be followed.
 
  Example A patient is admitted with unstable angina and acute congestive heart failure. The
1: unstable angina is treated with nitrates, and intravenous Lasix is given to manage the
heart failure. Both diagnoses meet the definition of principal diagnosis equally, and
either may be sequenced first.
     
  Example A patient is admitted with acute atrial fibrillation with rapid ventricular response and is
2: also in heart failure with pulmonary edema. The patient is digitalized to reduce the
ventricular rate and given intravenous Lasix to reduce the cardiogenic pulmonary
edema. Both conditions meet the definition of principal diagnosis equally, and either
may be sequenced first.
     
  Example A patient is admitted with severe abdominal pain, nausea, and vomiting due to acute
3: pyelonephritis and diverticulitis. Both underlying conditions are treated, and the
physician believes both equally meet the criteria for principal diagnosis. In this
instance, either condition may be listed as principal diagnosis..
 
2. Two or more comparable or contrasting conditions: In the rare instance that two or
more comparable or contrasting conditions are documented as either/or (or similar
 terminology), both diagnoses are coded as though confirmed and the principal
diagnosis is designated according to the circumstances of the admission and the
diagnostic workup and/or therapy provided. When no further determination can be
made as to which diagnosis more closely meets the criteria for principal diagnosis,
either may be sequenced first. Note that this guideline does not apply for outpatient
encounters.
 
  Example A patient with the same complaints as those outlined in example 3 above is admitted
1: with a final diagnosis of acute pyelonephritis versus diverticulum of the colon. The
patient is treated symptomatically and discharged for further studies. In this case, both
conditions meet the criteria for principal diagnosis equally, and either can be
designated as the principal diagnosis.
     
  Example The treatment of another patient with the same symptoms and the same final diagnoses
2: is directed almost entirely toward the acute pyelonephritis, indicating that the physician
considers this condition the more likely problem and that, after study, it is the condition
that occasioned the admission. In this case, both conditions are coded, but the acute
pyelonephritis is sequenced first because of the circumstances of the admission.
 
3. Original treatment plan not carried out: In a situation in which the original treatment
plan cannot be carried out due to unforeseen circumstances, the criteria for
designation of the principal diagnosis do not change. The condition that occasioned
the admission is designated as the principal diagnosis even though the planned
treatment was not carried out.
 
  Example A patient with benign hypertrophy of the prostate is admitted for the purpose of a
1: transurethral resection of the prostate (TURP). Shortly after admission, but before the
patient is taken to the operating suite, the patient falls and sustains a fracture of the left
femur. The TURP is canceled; hip pinning is carried out the following day. The
principal diagnosis remains benign hypertrophy of the prostate even though that
condition was not treated.
     
  Example A patient with a diagnosis of carcinoma of the breast confirmed from an outpatient
2: biopsy is admitted for the purpose of modified radical mastectomy. Before the
preoperative medications are administered the next morning, the patient indicates that
she has decided against having the procedure until she is able to consider possible
alternative treatment more thoroughly. No treatment is given, and she is discharged.
The carcinoma of the breast remains the principal diagnosis because it is the condition
that occasioned the admission even though no treatment was rendered.

Other Diagnoses
 
     Other reportable diagnoses are defined as those conditions that coexist at the time
of admission or develop subsequently or affect patient care for the current hospital
episode. Diagnoses that have no impact on patient care during the hospital stay are not
reported even when they are present. Diagnoses that relate to an earlier episode and
have no bearing on the current hospital stay are not reported.
      For UHDDS reporting purposes, the definition of "other diagnosis" includes only
those conditions that affect the episode of hospital care in terms of any of the
following:
 
 Clinical evaluation
 Therapeutic treatment
 Further evaluation by diagnostic studies, procedures, or consultation
 Extended length of hospital stay
 Increased nursing care and/or other monitoring

All these factors are self-explanatory except the first. Clinical evaluation means that
the physician is aware of the problem and is evaluating it in terms of testing,
consultations, or close clinical observation of the patient's condition. In most cases, a
patient who is being evaluated clinically will also fit into one of the other criteria.
Note that a physical examination alone does not qualify as further evaluation or
clinical evaluation; the physical examination is a routine part of every hospital
admission. No particular order is mandated for sequencing other diagnoses. The more
significant diagnoses should be sequenced early in the list when the number of
diagnoses that may be reported is limited.

Reporting Guidelines for Other Diagnoses

 
     The following guidelines and examples should be studied carefully in order to
understand the rationale for determining other diagnoses that should be reported:
 
 
1. Previous conditions stated as diagnoses: Physicians sometimes include in the
diagnostic statement historical information or status post procedures performed on a
previous admission that have no bearing on the current stay. Such conditions are not
reported. However, history codes (categories Z80-Z87; subcategories Z91.4-, Z91.5-,
and Z91.8; and category Z92) may be used as secondary codes if the historical
condition or family history has an impact on current care or influences treatment.
 
  Example: A patient is admitted with acute myocardial infarction; the physician notes in the
history that the patient is status post cholecystectomy and had been hospitalized one
year earlier for pneumonia. At discharge, the physician documents the final diagnoses
as acute myocardial infarction, status post cholecystectomy, and history of
pneumonia. Only the acute myocardial infarction is coded and reported; the other
conditions included in the diagnostic statement have no bearing on the current
episode of care.
 
2. Other diagnosis with no documentation supporting reportability: If the physician has
included a diagnosis in the final diagnostic statement, it should ordinarily be coded. If
there is no supporting documentation in the medical record, however, the physician
should be consulted as to whether the diagnosis meets reporting criteria; if so, the
physician should be asked to add the necessary documentation. Reporting of
conditions for which there is no supporting documentation is in conflict with UHDDS
criteria.
 
 
  Example A 10-year-old boy is admitted with open fracture of the tibia and fibula following a
1: bicycle accident. On physical examination, the physician notes that there is a nevus
on the leg and that the patient has a small, asymptomatic inguinal hernia. All these
diagnoses are documented on the face sheet. The fracture is reduced with internal
fixation, but neither the nevus nor the hernia is treated or further evaluated on this
admission. The nevus and hernia are not reported because there is nothing to indicate
that they had any effect on the episode of care.
     
  Example A patient is admitted with an acute myocardial infarction. The physician also includes
2: in the diagnostic statement a strabismus and a bunion noted on the physical
examination. Review of the medical record reveals that no further reference to these
conditions was made in terms of further evaluation or treatment; therefore, no codes
for either the strabismus or the bunion are assigned.
 
3. Chronic conditions that are not the thrust of treatment: The criteria for selection of
chronic conditions to be reported as "other diagnoses" include the severity of the
condition, the use or consideration of alternative measures or an increase in nursing
care required in the treatment of the principal diagnosis due to the coexisting
condition, the use of diagnostic or therapeutic services for the particular coexisting
condition, the need for close monitoring of medications because of the coexisting
condition, or modifications of nursing care plans because of the coexisting condition.
 
Chronic conditions such as (but not limited to) hypertension, Parkinson's disease,
chronic obstructive pulmonary disease, and diabetes mellitus are systemic diseases
that ordinarily should be coded even in the absence of documented intervention or
further evaluation. Some chronic conditions affect the patient for the rest of his or her
life; such conditions almost always require some form of continuous clinical
evaluation or monitoring during hospitalization and therefore should be coded. This
advice applies to inpatient coding.
 
For outpatient encounters/visits, chronic conditions that require or affect patient care
treatment or management should be coded.
 
  Example A patient is admitted following a hip fracture, and a diagnosis of Parkinson's disease
1: is noted in the history and physical examination. Nursing notes indicate that the
patient required additional care because of the Parkinson's disease. Both diagnoses are
reported.
     
  Example A patient is admitted with pneumonia, and the presence of diabetes mellitus is
2: documented in the record. Blood sugars are monitored by laboratory studies, and
nursing personnel also check blood sugars before each meal. The patient is continued
on his diabetic diet. Although no active treatment is provided, ongoing monitoring is
required, and the condition is reported.
     
  Example A patient is admitted with acute diverticulitis, and the physician documents in the
3: admitting note a history of hypertension. Review of the medical record indicates that
blood pressure medications were given throughout the stay. The hypertension is
reportable, and the physician should be asked to add it to the diagnostic statement.
     
  Example A patient is admitted in congestive heart failure. She has known hiatal hernia and
4: degenerative arthritis. Neither condition is further evaluated or treated; by their
nature, the conditions do not require continuing clinical evaluation. Only the code for
the congestive heart failure is assigned; the other conditions are not reportable.
     
  Example A 60-year-old diabetic patient is transferred from an extended care facility for
5: treatment of a pressure ulcer. The physician notes in the history and physical exam
that the patient is status post left below-the-knee amputation due to peripheral
vascular disease. This condition requires additional nursing assistance and is reported.
 
4. Conditions that are an integral part of a disease process should not be reported as -
 additional diagnoses, unless otherwise instructed by the classification.
 
  Example A patient is admitted with nausea and vomiting due to infectious gastroenteritis.
1: Nausea and vomiting are common symptoms of infectious gastroenteritis and are not
reported.
     
  Example A patient is admitted with severe joint pain and rheumatoid arthritis. Severe joint pain
2: is a characteristic part of rheumatoid arthritis and is not reportable.
     
  Example A patient is seen in the physician's office complaining of urinary frequency and is
3: diagnosed with benign prostatic hypertrophy. Although urinary frequency is a
common symptom of benign prostatic hypertrophy, both conditions are reported
because of the instructional note in the Tabular List under code N40.1 to use
additional codes to identify associated symptoms when specified.
 
5. Conditions that are not an integral part of a disease process should be coded when
present.
 
  Example A patient is admitted by ambulance following a cerebrovascular accident suffered at
1: work. The patient was in a coma but gradually recovers consciousness. Diagnosis at
discharge is reported as cerebrovascular thrombosis with coma. In this case, coma is
coded as an additional diagnosis because it is not implicit in a cerebrovascular
accident and is not always present.
     
  Example A five-year-old boy is admitted with a 104-degree fever associated with acute
2: pneumonia. During the first 24 hours, the patient also experiences convulsions due to
the high fever. Both the pneumonia and the convulsions are reported because
convulsions are not routinely associated with pneumonia. No code is assigned for
fever, however, because it is commonly associated with pneumonia.
 
6. Abnormal findings: Codes from sections R70-R97 for nonspecific abnormal findings
(laboratory, radiology, pathology, and other diagnostic results) should be assigned
only when the physician has not been able to arrive at a related diagnosis but indicates
that the abnormal finding is considered to be clinically significant by listing it in the
diagnostic statement. This differs from the coding practices in the outpatient setting
 when one is coding encounters for diagnostic tests that have been interpreted by a
physician.
 
A code should never be assigned on the basis of an abnormal finding alone. To make
a diagnosis on the basis of a single lab value or abnormal diagnostic finding is risky
and carries the possibility of error. A value reported as either lower or higher than the
normal range does not necessarily indicate a disorder. Many factors influence the
values in a lab sample; these include the collection device, the method used to
transport the sample to the lab, the calibration of the machine that reads the values,
and the condition of the patient. For example, a patient who is dehydrated may show
an elevated hemoglobin due to increased viscosity of the blood. When findings are
clearly outside the normal range and the physician has ordered other tests to evaluate
the condition or has prescribed treatment without documenting an associated
diagnosis, it is appropriate to ask the physician whether a diagnosis should be added
or whether the abnormal finding should be listed in the diagnostic statement.
Incidental findings on X-ray, such as asymptomatic hiatal hernia or a diverticulum,
should not be reported unless further evaluation or treatment is carried out.
 
  Example A low potassium level treated with intravenous or oral potassium is clinically
1: significant and should be brought to the attention of the physician if no related
diagnosis has been recorded.
     
  Example A hematocrit of 28 percent, even though asymptomatic and not treated, is evaluated
2: with serial hematocrits. Because the finding is outside the range of normal laboratory
values and has been further evaluated, the physician should be asked whether an
associated diagnosis should be documented.
     
  Example A routine preoperative chest X-ray on an elderly patient reveals collapse of a
3: vertebral body. The patient is asymptomatic, and no further evaluation or treatment is
carried out. Collapse of a vertebral body is a common finding in elderly patients and
is insignificant for this episode.
     
  Example In the absence of a cardiac problem, an isolated electrocardiographic finding of
4: bundle branch block is ordinarily not significant, whereas a finding of a Mobitz II
block may have important implications for the patient's care and warrants asking the
physician whether it should be reported for this admission.
     
  Example The physician lists an abnormal sedimentation rate as part of the diagnostic
5: . statement. The physician has been unable to make a definitive diagnosis during the
hospitalization in spite of further evaluation and considers the abnormal finding a
significant clinical problem. Code R70.0, Elevated erythrocyte sedimentation
rate, should be assigned.

Admitting Diagnosis
 
     Although the admitting diagnosis is not an element of the UHDDS, it must be
reported for some payers and may also be useful in quality-of-care studies. Ordinarily,
 only one admitting diagnosis can be reported. The inpatient admitting diagnosis may
be reported as one of the following:
 
 A significant finding (symptom or sign) representing patient distress or
an abnormal finding on outpatient examination
 A possible diagnosis based on significant findings (working diagnosis)
 A diagnosis established on an ambulatory care basis or during a
previous hospital admission
 An injury or a poisoning
 A reason or condition that is not actually an illness or injury, such as a
follow-up examination or pregnancy in labor

     If the admitting diagnosis is reported, the code should indicate the diagnosis
provided by the physician at the time of admission. Although the admitting diagnosis
may not agree with the principal diagnosis on discharge, the admitting diagnosis
should not be changed to conform to the principal diagnosis. Examples of admitting
diagnoses and subsequent principal diagnoses follow:
 
  • Admitting: K92.2 Gastrointestinal bleeding
    Principal: K26.0 Acute duodenal ulcer with hemorrhage
         
  • Admitting: N63.10 Lump in right breast
    Principal: C50.911 Carcinoma of right female breast
         
  • Admitting: K81.0 Acute cholecystitis
    Principal: K80.00 Acute cholecystitis with cholelithiasis
         
  • Admitting: I50.9 Congestive heart failure
    Principal: I21.09 Acute myocardial infarction, anterior wall
         
  • Admitting: I21.3 Suspected myocardial infarction
    Principal: I71.01 Dissection of thoracic aorta

PROCEDURES
 
The UHDDS requires that all significant procedures be reported. The UHDDS
definitions of significant procedures and other reporting guidelines are discussed in
chapter 9 of this handbook, along with other information on coding operations and
procedures.

RELATIONSHIP OF UHDDS TO OUTPATIENT REPORTING

 
The UHDDS definition of principal diagnosis does not apply to the coding of
outpatient encounters. In contrast to inpatient coding, no "after study" element is
involved 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 an encounter, the
documented chief complaint should be reported as the reason for the encounter/visit.

RELATIONSHIP OF UHDDS TO LONG-TERM CARE REPORTING

 
The UHDDS definition of principal diagnosis has been expanded since its initial
development so that it now applies to coding in all nonoutpatient settings (acute care,
short-term care, long-term care, and psychiatric hospitals; home health agencies;
rehabilitation facilities; nursing homes; hospice facilities; and so forth). Other
diagnoses documented by the physician (e.g., chronic conditions) that affect a
resident's continued care should also be coded. However, in long-term care (LTC)
settings, there are some differences in the application of the principal and secondary
diagnoses.
     The diagnostic listing in LTC is dynamic, depending on many factors including the
point in time when codes are assigned. LTC has a longer time frame than an acute
care stay: ICD-10-CM codes are assigned upon admission; concurrently as diagnoses
arise; and at the time of discharge, transfer, or expiration of a resident.
     The first-listed diagnosis is the diagnosis chiefly responsible for the admission to,
or continued residence in, a nursing facility and should be sequenced first. For
example, when an admission is coded, the first-listed diagnosis is the condition
chiefly responsible for the admission to the facility. If the diagnosis codes are
assigned during the resident's stay, the first-listed diagnosis is the condition chiefly
responsible for the continued stay in the facility.
 
  Example 1: A patient is admitted to a nursing home for
convalescence following an acute illness. Code
assignment is based on the condition being treated as
documented in the medical record. It would also be
appropriate to assign codes for any late effects, residual
conditions, signs, or symptoms that are present. When
the reason for the admission is strictly for
convalescence and there is no other definitive
diagnosis, assign code Z51.89, Encounter for other
specified aftercare, as the first-listed diagnosis.
     
  Example 2: A patient is admitted to LTC following hospital
treatment of a fracture of the right femur. The reason
for the LTC admission is to allow the patient to regain
strength and the fracture to heal. Assign
code S72.90XD, Unspecified fracture of right femur,
subsequent encounter for closed fracture with
routine healing, as the principal diagnosis. The
seventh character "D" is used for encounters after the
patient has received active treatment for the condition
and is now receiving routine care during the healing or
recovery phase. Code any other coexistent conditions
that require treatment.
     
  Example 3: A nursing home resident is transferred to the hospital
 for treatment of pneumonia. She returns to the nursing
home still receiving antibiotics for the pneumonia.
However, the main reason she is returning to the
nursing home is because this has been her residence
since developing a cerebrovascular accident (CVA)
with residuals several years ago. The appropriate code
from subcategory I69.3, Sequelae of cerebral infarction,
is assigned as the principal diagnosis to identify the
neurologic deficits that resulted from the acute CVA.
The appropriate code for the pneumonia is assigned as
a secondary diagnosis for as long as the patient receives
treatment for the condition.

ETHICAL CODING AND REPORTING

 
Whereas coded medical data are used for a variety of purposes, they have become
increasingly important in determining payment for health care. Medicare
reimbursement depends on the following:
 
 The correct designation of the principal diagnosis
 The presence or absence of additional codes that represent
complications, comorbidities, or major complications or comorbidities as
defined by the Medicare severity-adjusted diagnosis-related groups system
 Procedures performed

Other third-party payers may follow slightly different reimbursement methods, but the
accuracy of ICD-10-CM and ICD-10-PCS coding is always vital.
     Accurate and ethical ICD-10-CM and ICD-10-PCS coding depends on correctly
following all instructions in the coding manuals as well as all official guidelines
developed by the cooperating parties and coding advice published in the American
Hospital Association's quarterly Coding Clinic. Accurate and ethical reporting
requires the correct selection of those conditions that meet the criteria set by the
UHDDS and the official guidelines mentioned above. Over-coding and over-reporting
may result in higher payment, but those practices are unethical and may be considered
fraudulent. On the other hand, it is important to be sure that all appropriate codes are
reported, as failure to include all diagnoses or procedures that meet reporting criteria
may result in financial loss for the health care provider.
     It is important abide by the American Health Information Management
Association Standards of Ethical Coding, which are available for download at
www.ahima.org
[http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_024277.hcsp?
dDocName=bok1_024277].
     Occasionally, certain codes are identified by Medicare or another payer as being
unacceptable as the principal diagnosis. This does not mean that the code should not
be assigned when it is correct; it means that the third-party payer may question or
deny payment. Coding professionals must code correctly and then make whatever
adjustment is required for reportingor run the risk of developing incorrect coding
practices that will distort data used for other purposes.
     Hospitals sometimes identify a need to code nonreportable diagnoses or
procedures for internal use; this is acceptable if the facility has a system for
maintaining this information outside the reporting system.
     There are a variety of payment policies that may have an impact on coding. Many
of those policies may contradict each other or may be inconsistent with
ICD-10-CM/PCS rules and conventions. Therefore, it is not possible to write coding
guidelines that are consistent with all existing payer guidelines.
     The following advice is shared to help providers resolve coding disputes with
payers:
 
 First, determine whether the problem is really a coding dispute and not
a coverage issue. Always contact the payer for clarification if the reason for
the denial is unclear.
 If a payer really does have a policy that clearly conflicts with official
coding rules or guidelines, every effort should be made to resolve the issue
with the payer. Provide the applicable coding rule/guideline to the payer.
 If a payer refuses to change its policy, obtain the payer requirements in
writing. If the payer refuses to provide its policy in writing, document all
discussions with the payer, including dates and the names of individuals
involved in the discussion. Confirm the existence of the policy with the payer's
supervisory personnel.
 Keep a permanent file of the documentation obtained regarding payer
coding policies. It may come in handy in the event of an audit.