4 icd 10

Question 1

UHDDS

Answer 1

The Uniform Hospital Discharge Data Set (UHDDS) is used for reporting inpatient data.

Question 2

The following items are always found in the UHDDS:

Answer 2

• • demographic
• • payer
• • Hospital identification
• • Principal diagnosis
• • Other diagnoses that have specific significance
• • All significant procedures

Question 3

MS-DRG system

Answer 3

Medicare severity-adjusted diagnosis-related groups system; a patient classification system used in hospital inpatient reimbursement

Question 4

Other reportable diagnoses

Answer 4

conditions that coexist at the time of admission, develop subsequently, or affect patient care during the hospital stay

Question 5

Principal diagnosis

Answer 5

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

Question 6

The admitting diagnosis is not an element of the UHDDS.

Answer 6

Diagnoses that have no impact on patient care or that are related to an earlier episode are not reported on the UHDDS.

Question 7

The Uniform Hospital Discharge Data Set (UHDDS) is used for

Answer 7

reporting inpatient data in acute care, short-term care, and long-term care hospitals.

Question 8

It uses a minimum set of items based on standard definitions that could

Answer 8

provide consistent data for multiple users.

Question 9

Only those items that met the following criteria were included:

Answer 9

Easily identified
Readily defined
Uniformly recorded
Easily abstracted from the medical record

Question 10

UHDDS use is required for

Answer 10

claims reporting for Medicare and Medicaid patients.

many other health care payers use most of the UHDDS as a uniform billing system.

Question 11

The UHDDS requires the following items:

Answer 11

Principal diagnosis
Other diagnoses that have significance for the specific hospital episode
All significant procedures

Question 12

The four cooperating parties responsible for developing and maintaining ICD-10-CM

Answer 12

AHA -American Hospital Association,
AHIMA - American Health Information Management Association,
CMS - Centers for Medicare & Medicaid Services
NCHS - National Center for Health Statistics)

Question 13

The AHA AHIMA CMS & NCHS have developed

Answer 13

official guidelines for
designating the principal diagnosis
identifying other diagnoses that should be reported in certain situations.

Question 14

The UHDDS also contains a core of general information that

Answer 14

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.

Question 15

The UHDDS definitions were originally developed in

Answer 15

1985 for hospital reporting of inpatient data elements. Since that time, the application of UHDDS definitions has been expanded to include all nonoutpatient settings.
psychiatric hospitals, home health agencies, rehabilitation facilities, nursing homes, and other settings.

Question 16

principal diagnosis is defined as

Answer 16

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

Question 17

It is important that the principal diagnosis be designated correctly because

Answer 17

cost comparisons
care analysis
utilization review.
It is crucial for reimbursement because many third-party payers (including Medicare) base reimbursement primarily on principal diagnosis.

Question 18

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.
(if a single bill is submitted to a payer for inpatient and outpatient bills

Answer 18

Hospitals should apply codes for the current encounter based on individual payer billing instructions.

Question 19

Admission following medical observation unit :

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.

Answer 19

The principal diagnosis reported is the medical condition that led to the hospital admission.

Question 20

Admission following postoperative observation:

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,

Answer 20

“that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Question 21

Admission from outpatient surgery: A patient undergoing outpatient surgery may be subsequently admitted for continuing inpatient care at the same hospital.

Answer 21

if inpatient admission

is a complication, assign the complication as the principal diagnosis.

–If no complication or other condition is documented, assign the reason for the outpatient surgery as the principal diagnosis.

–If another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.

Question 22

Two or more diagnoses that equally meet the definition for principal diagnosis:

Answer 22

either may be sequenced first when neither the Alphabetic Index nor the Tabular List directs otherwise.

However,

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.

Question 23

Two or more comparable or contrasting conditions:

Answer 23

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.

Question 24

When a symptom is followed by contrasting/comparative diagnoses,

Answer 24

the symptom code is sequenced first. However, if the symptom code is integral to each of the conditions listed, no additional code for the symptom is reported. Codes are assigned for all listed contrasting/comparative diagnoses.

Question 25

Example 1: A patient is admitted for workup because of severe fatigue. The discharge diagnosis is recorded as fatigue, due to either depressive reaction or hypothyroidism.

Answer 25

In this case, the symptom code for fatigue is designated the principal diagnosis, with additional codes assigned for both the depressive reaction and the hypothyroidism.

Question 26

The discharge diagnosis is stated as gastrointestinal bleeding, due to either acute gastritis or angiodysplasia.

Answer 26

In this case, the diagnoses are coded as contrasting/comparative diagnoses, and no separate code is assigned for the bleeding because the codes for both conditions include any associated bleeding.

Question 27

Original treatment plan not carried out:

Answer 27

The condition that occasioned the admission is designated as the principal diagnosis even though the planned treatment was not carried out.

Question 28

Example 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.

Answer 28

The principal diagnosis remains hypertrophy of the prostate even though that condition was not treated.

Question 29

example: A patient with a diagnosis of carcinoma of the breast confirmed from an outpatient 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.

Answer 29

The carcinoma of the breast remains the principal diagnosis because it is the condition that occasioned the admission even though no treatment was rendered.

Question 30

Other reportable diagnoses are defined as

Answer 30

those conditions that coexist at the time of admission or develop subsequently or affect patient care for the current hospital episode.

Question 31

Diagnoses that have no impact on patient care during the hospital stay are not reported even when they are present.

Answer 31

true

Question 32

Diagnoses that relate to an earlier episode and have no bearing on the current hospital stay are not reported.

Answer 32

true

Question 33

“other diagnosis” includes only those conditions that affect the episode of hospital care in terms of any of the following:

Answer 33

Clinical evaluation
Therapeutic treatment
Further evaluation by diagnostic studies, procedures, or consultation
Extended length of hospital stay
Increased nursing care and/or other monitoring

Question 34

Clinical evaluation means

Answer 34

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.

Question 35

a physical examination alone does not qualify as further evaluation or clinical evaluation

Answer 35

True

the physical examination is a routine part of every hospital admission.

Question 36

No particular order is mandated for sequencing other diagnoses.

Answer 36

true but
The more significant diagnoses should be sequenced early in the list when the number of diagnoses that may be reported is limited.

Question 37

Reporting Guidelines for Other Diagnoses

Answer 37

1. Previous conditions stated as diagnoses:
2. Other diagnosis with no documentation supporting reportability:
3. Chronic conditions that are not the thrust of treatment:
4. Conditions that are an integral part of a disease process should not be reported as additional diagnoses, unless otherwise instructed by the classification.
5. Conditions that are not an integral part of a disease process should be coded when present.
6. Abnormal findings:

Question 38

never assign a code on the basis of an abnormal finding alone.

Answer 38

true

To make a diagnosis on the basis of a single lab value or abnormal diagnostic finding is risky and carries the possibility of error.

Question 39

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

Answer 39

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.

Question 40

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,

Answer 40

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.

Question 41

3. Chronic conditions that are not the thrust of treatment: The criteria for selection of chronic conditions to be reported as “other diagnoses” include

Answer 41

severity of the condition,

the use or consideration of alternative measures

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,

modifications of nursing care plans because of the coexisting condition.

Question 42

systemic diseases

Answer 42

Chronic conditions such as
 hypertension, 
Parkinson's disease, 
chronic obstructive pulmonary disease,
diabetes mellitus 

ordinarily should be coded even in the absence of documented intervention or further evaluation.

they affect the patient for the rest of his or her life; almost always require some form of continuous clinical evaluation or monitoring during hospitalization and therefore should be coded. This advice applies to inpatient coding.

Question 43

For outpatient encounters/visits, chronic conditions that require or affect patient care treatment or management .

Answer 43

should be coded

Question 44

Example 1: A patient is admitted following a hip fracture, and a diagnosis of Parkinson’s disease is noted in the history and physical examination. Nursing notes indicate that the patient required additional care because of the Parkinsonism.

Answer 44

Both diagnoses are reported.

Question 45

Example 2: A patient is admitted with pneumonia, and the presence of diabetes mellitus is 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,

Answer 45

the condition is reported.

Question 46

Example 3: A patient is admitted with acute diverticulitis, and the physician documents in the admitting note a history of hypertension. Review of the medical record indicates that blood pressure medications were given throughout the stay.

Answer 46

The hypertension is reportable, and the physician should be asked to add it to the diagnostic statement.

Question 47

Example 4: A patient is admitted in congestive heart failure. She has known hiatal hernia and degenerative arthritis. Neither condition is further evaluated or treated; by their nature, the conditions do not require continuing clinical evaluation.

Answer 47

Only the code for the congestive heart failure is assigned; the other conditions are not reportable.

Question 48

Example 5: A 60-year-old diabetic patient is transferred from an extended care facility for 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.

Answer 48

This condition requires additional nursing assistance and is reported.

Question 49

Conditions that are an integral part of a disease process

Answer 49

should not be reported as additional diagnoses, unless otherwise instructed by the classification.

Question 50

Example 1: A patient is admitted with nausea and vomiting due to infectious gastroenteritis.

Answer 50

Nausea and vomiting are common symptoms of infectious gastroenteritis and are not reported.

Question 51

Example 2: A patient is admitted with severe joint pain and rheumatoid arthritis.

Answer 51

Severe joint pain is a characteristic part of rheumatoid arthritis and is not reportable.

Question 52

Example 3: A patient is seen in the physician’s office complaining of urinary frequency and is diagnosed with benign prostatic hypertrophy.

Answer 52

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.

Question 53

Conditions that are not an integral part of a disease process

Answer 53

should be coded when present.

Question 54

Example 1: A patient is admitted by ambulance following a cerebrovascular accident suffered at work. The patient was in a coma but gradually recovers consciousness.

Answer 54

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.

Question 55

Example 2: A five-year-old boy is admitted with a 104-degree fever associated with acute pneumonia. During the first 24 hours, the patient also experiences convulsions due to the high fever.

Answer 55

Both the pneumonia and the convulsions are reported because convulsions are not routinely associated with pneumonia. Fever is commonly associated with pneumonia, however, and no code is assigned.

Question 56

Example 1: A low potassium level treated with intravenous or oral potassium

Answer 56

is clinically significant and should be brought to the attention of the physician if no related diagnosis has been recorded.

Question 57

Example 2: A hematocrit of 28 percent, even though asymptomatic and not treated, is evaluated with serial hematocrits.

Answer 57

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.

Question 58

Example 3: A routine preoperative chest X-ray on an elderly patient reveals collapse of a vertebral body. The patient is asymptomatic, and no further evaluation or treatment is carried out.

Answer 58

This is a common finding in elderly patients and is insignificant for this episode.

Question 59

Example 4: In the absence of a cardiac problem, an isolated electrocardiographic finding of bundle branch block is ordinarily not significant, whereas a finding of a Mobitz II block may have important implications for the patient’s care

Answer 59

warrants asking the physician whether it should be reported for this admission.

Question 60

Example 5: . The physician lists an abnormal sedimentation rate as part of the diagnostic statement.

Answer 60

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.

Question 61

Admitting Diagnosis

Answer 61

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.

Question 62

The inpatient admitting diagnosis may be reported as one of how many

Answer 62

See the next five (5)

Question 63

A significant finding (symptom or sign)

Answer 63

representing patient distress or an abnormal finding on outpatient examination

Question 64

(working diagnosis)

Answer 64

A possible diagnosis based on significant findings

Question 65

A diagnosis established on an ambulatory care basis or

Answer 65

during a previous hospital admission

Question 66

An injury or a poisoning

Answer 66

true

Question 67

A reason or condition that is not actually an illness or injury,

Answer 67

such as a follow-up examination or pregnancy in labor

Question 68

T or F
If the admitting diagnosis is reported, the code should indicate the diagnosis provided by the physician at the time of admission.

Answer 68

T
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.

Question 69

T or F

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

Answer 69

T
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.

Question 70

If the physician does not identify a definite condition or problem at the conclusion of a visit or an encounter,

Answer 70

the coder should report the documented chief complaint as the reason for the encounter/visit.

Question 71

Whereas coded medical data are used for a variety of purposes, they have become increasingly important in determining payment for health care.

Answer 71

T

Question 72

Medicare reimbursement depends on

Answer 72

correct designation of the principal diagnosis

presence or absence of additional codes that represent: complications/comorbidities,

Procedures performed

Question 73

Accurate and ethical ICD-10-CM and ICD-10-PCS coding depends on

Answer 73

correctly following all instructions in the

coding manuals
all official guidelines developed by the cooperating parties
coding advice published in the AHA’s quarterly Coding Clinic.

Question 74

Over-coding and over-reporting

Answer 74

may result in higher payment, but it is unethical and may be considered fraudulent.

Question 75

it is important to be sure that all appropriate codes are reported,

Answer 75

failure to include all diagnoses or procedures that meet reporting criteria may result in financial loss for the health care provider.

Question 76

T or F
It is important for coders to abide by the American Health Information Management Association Standards of Ethical Coding

Answer 76

T

They are available for download at http://www.ahima.org/about/ethicsstandards.aspx.

Question 77

certain codes are identified by Medicare or another payer as being unacceptable as the principal diagnosis.

Answer 77

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.

Question 78

Why It is important to code correctly and then make whatever adjustment is required for reporting.

Answer 78

Otherwise, the coder runs the risk of developing incorrect coding practices that will distort data used for other purposes.

Question 79

is it acceptable for Hospitals to code nonreportable diagnoses or procedures for internal use

Answer 79

Yes, if the facility has a system for maintaining this information outside the reporting system.

Question 80

What is the first advice to help providers resolve coding disputes with payers:

Answer 80

Determine it is coding and not a coverage issue

Question 81

If a payer really does have a policy that clearly conflicts with official coding rules or guidelines,

Answer 81

ery effort should be made to resolve the issue with the payer.

Question 82

Effort 1.

Answer 82

Provide the applicable coding rule/guideline to the payer.

Question 83

Effort 2.

Answer 83

contact the Medicare Administrative Contractor (MAC) for clarification.–The MAC should be able to provide you with information as to which Regional Office has jurisdiction over your area.

Question 84

Effort 3.

Answer 84

If you are not satisfied with the answer you receive, follow up with the Centers for Medicare & Medicaid Services Regional Office.

Question 85

If a payer refuses to change its policy,

Answer 85

obtain the payer requirements in writing.

Question 86

If the payer refuses to provide its policy in writing,

Answer 86

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.

Question 87

Keep a permanent file of the documentation obtained regarding payer coding policies.

Answer 87

It may come in handy in the event of an audit.