EHRGo Assignment: UHHDS and the EHR

Uniform Hospital Discharge Data Set – UHDDS P o sted o n July 2 5 , 2 0 1 5

Medical Billing Coding World

Implemented in 1974, the Uniform Hospital Discharge Data Set (UHDDS) was originally an initiative by

the predecessor of today’s Department of Health and Human Services (HHS), the Department of Health,

Education, and Welfare.

The creation of the UHDDS is indirectly a result of the founding of the Medicare program in 1965. As the

federal government was becoming increasingly involved in healthcare, analysts realized the importance

of creating a standardized system of medical coding that would allow for an easier comparison between

hospitals.

Having comparable data could help to determine which hospitals were best at treating patients, which

could in turn serve as models to lower costs for the government saved from patients who were not

repeatedly readmitted. This data could also be used to compare the reimbursement rates of different

hospitals for similar medical procedures, and thereby work towards a standardized system of

reimbursement for the federal government nationwide. Until this point prices could vary greatly from

region to region, and even between hospitals in the same city, because there was not a national

reimbursement system in place.

Standardization in reimbursement rates also helped hospitals move towards standardization in quality

of care. This provided a measuring stick for under-performing hospitals offering sub-standard levels of

care, and once these facilities were identified measures could be taken to improve them. While the

importance of this is inherently obvious, remember that when Medicare was created in 1965

segregation was still rampant in the United States – all the more reason to use data to compel hospitals

to provide equal levels of care.

UHDDS Today

Since its implementation in 1974 the UHDDS has undergone several revisions. While this information is

specific to hospitals that provide medical services for those covered by Medicare and Medicaid, it has

become standard practice for all insurance companies to gather information similar to the UHDDS

because of the recognized value of having comparable data. Medical billing and coding professionals will

recognize the following information as being required on today’s UHDDS forms:

• Hospital or facility identification number or code

• Expected insurance payer number or code

• Sex, age, and race of the patient

• Significant medical procedures performed

• Principal diagnosis

• Additional significant diagnoses

Today in addition to hospitals, facilities such as the following might use the UHDDS:

• Rehabilitation facilities

• Nursing and retirement communities

• Home health care providers

Medical billing and coding professionals who work in these types of facilities with Medicare and

Medicaid recipients should become adept at filing the UHDDS. This can affect the overall rate of

reimbursement, so coding correctly can improve a medical service provider’s bottom line. Some points

that may prove to be tricky include:

• The inclusion of other diagnoses – only other diagnoses that are part of the immediate health

care services provided should be reported

• Order of other diagnoses – when reporting these, it can be important to list the most serious

diagnoses first, especially if there is a limit on the amount that may be listed

• Inclusion of previous diagnoses – even if these are reported in a medical record by a doctor,

billing and coding professionals should not report these on the UHDDS if they do not have a

bearing on the current medical services performed

• Inclusion of chronic conditions – even if chronic conditions are not part of the immediate

medical services provided, they should be reported because they must be constantly monitored

and evaluated

https://medicalbillingcodingworld.com/2015/07/uniform-hospital-discharge-data-set-uhdds/