Other diagnosis with no supporting documentation - The physician should be queried as to
whether the included diagnosis meets reporting criteria, and if so, the physician should add the
necessary supporting documentation to the medical record.
Admission from outpatient surgery - If due to compli...
Chapter 4: UHDDS
Other diagnosis with no supporting documentation - The physician should be queried as to
whether the included diagnosis meets reporting criteria, and if so, the physician should add the
necessary supporting documentation to the medical record.
Admission from outpatient surgery - If due to complication, assign the complication as the
principal diagnosis.
If no complication or other reason, assign the reason for outpatient surgery as the principal diagnosis.
If for condition unrelated to surgery, assign the unrelated condition as the principal diagnosis.
UHDDS - Uniform Hospital Discharge Data Set
used for reporting inpatient data in acute care, short-term care, and long-term care hospitals
principal diagnosis - the condition established after study to be chiefly responsible for admission
of the patient to the hospital
Admission following medical observation - The principal diagnosis is the medical condition that
led to the hospital admission.
Admission following postoperative observation - Use the UHDDS definition to assign principal
diagnosis
Admissions/encounters for rehabilitation - Assign the condition for which service is being
performed as the principal diagnosis.
Assign the appropriate aftercare code as the principal diagnosis if the condition is no longer present.
2 or more conditions that equally meet principal diagnosis - Either condition may be sequenced
first when neither the Alphabetic Index nor the Tabular List directs otherwise, except when treatment is
totally or primarily directed toward one condition or when one of the conditions would have required
inpatient care, that condition should be coded as the principal diagnosis.
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