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OCR for page 85
Code Admitting:
~I] ~ O CAR D 2:
Vl. Do admitting and principal
diagnoses agree?
~ t Yes
0 2 No
2
PRINCIPAL DIAGNOSIS
Vll.
Enter code
for principal
diagnosis which
is listed
above:
Principal
tom o
.'! in,
Appendix D
TOM RE-ABSTRACTING FORM
Total 1~~rancc Clan Number
~ 1 ~ 1 1 1 1 1 1 1 1] 1 1 1
Date of Discharge
Date of Birth
CONFIDENTIAL All information which would permit identification of the individual will be held in strict confidence, will be used
only by persons engaged ill and for the purposes of the study, and vail not be disclosed or released to others for any other purposes.
SSA Provider Number Coder l.D.
L1 1 1 1 1 172~/ 0~8
Sequential Number Medical Record Number
ml920
Code:_
1. ADMIT DATE
Do abstract and
re abstract agree?
If no, enter information
from SSA abstract
. . . If no, which is
correct?
Reason for
discrepancy
Enter code from
claims form
M M D D Y Y
mom
71 7O
0 1=Yes.
02- No ~
of
O 1--Y".
O 2-No -
0 1-Yes.
O 2-No --
M M D D Y Y
mom
2~ - 33
O t SSA abstract
0 2 Re-abstract
0 3 Either
0 4 Neither
0 1=Clerical
0 2= Completeness
1 - 341
1 1
35
5G
6'
M M D D Y Y
~ I f1 Im
36 -4,
11. DISCHARGE DATE
M M D D Y Y
_ __ _ _ _ _
42 ,1/
48
M M D D Y Y
mom
4;. 54
O t SSA abstract
0 2 Re~abstract
0 3 Either
0 4 Neither
O t=Clerical
0 2- Completeness
55
66-
M M D D Y Y
mllll~
57-62
111. SEX
0 1- Male
0 2 Female
n g- Not available
6
0 1=Male
a 2= Female
0 9= Not recorded
IV. __ is
ADMITTING DIAGNOSIS: Write out those diagnoses which appear in the
ER reports, H and P or adn~it notes. In column 1, indicate the part of the
record tram which each diagnosis is obtained. ER - Emergency Room
Reports; HP - History and Physical Reports; A = Admit notes. Using
these notes and reports, determine an admitting diagnosis and place an
A in column 2 by the appropriate diagnosis.
1 2
_ _
_ _
_ _-
64
0 1 SSA abstract
0 2 Re~abstract
0 3 E ither
~1 4 Neither
O 1=Clerical
0 2. Completeness
[3 1=Male
C] 2= Female
0 9- Not recorded
V.
PRINCIPAL DIAGNOSIS: Continue searching the medical record and
writing out diagnoses. In column 1 below, indicate the part of the record
from which each diagnosis is abstracted: F = Face sheet; D = Discharge
summary: 0 = Operation report; P = Pathology report; C = Consultations:
R ^ Reports. After reviewing these diagnoses and those listed in IS on the
left, determine a principal diagnosis using UHC)DS definitions. In column
2, place a P by that diagnosis.
1 2
_ _-
_ _-
_ _ _
Code Principal:
[10~0 lfi-1Q
If no, reason
for discrepancy
.-
0 1 Completeness
0 2 Coding refinement
0 3 Investigation
Q 4 Other ',
~ ---a 2 ~ 3 14
. . -—- 1
Do Abstract and It no, enter code I
re abstract agree? from SSA abstract |
- 1
0 1- Yes Principal |
0 2- No _ [II] [1 |
As 2':~1
. . . If no, which is
correct?
O 1 SSA abstract
~1 2 Re abstract
0 3 Either
n 4 Neither
85
Reasons for discrepancy {consider ordering first}
O O ~ Ordering SSA O 06 Cod ing
definition clerical
002 Ordering- Oot Coded
hospital list
003 Ordering
completeness
004 Ordering
judgment
005 Ordering
other
008 Coding
procedure
Tog Coding
jud~}rnent
0 10 Coding
other
.,7 ....
OCR for page 86
86
Appendix D
6
Write out all diagnoses in the order in
"ich they appear or' the Medicare claims form.
Code the first diagnosis listed
on the claim form
Principal
ml ~
34-37
Vlil.
ADDITIONAL DIAGNOSES:
1
4 5
Do abstract If no, enter
and information . . . If no, which Reason for
re-abstract from SSA is correct? discrepancy
agree? abstract
0 1 SSA abstract 0 1 Completeness
0 1 Yes 0 1 Yes 0 2 Re-abssract 0 2 Hospital
0 2 No _ 0 2 No O ~ Either definition
0 4 Neither G 3 Importance -
39 40 41 . 42
6
Do additional
diagnoses apt
pear in the
medical record?
Do additional
diagnoses apt
pear on the
claims form?
0 1 Yes
0 2 No
38
IX.
PROCEDURES: Write out the procedures as they appear in the medical record. In Column 1
indicate the part of the medical record from which each procedure was abstracted according
to the symbols listed for the diagnoses. In column 2, indicate the principal procedure by
entering the code P.
1 2
Code:
m 15
_ _-
_
1 2 3 4
Do abstract and If no, enter code
re-abstract agree? from SSA abstract
Principal
0 1 Yes
48 49-52
Principal
I f I I I
44_47
0 1 Yes
O2 No
43
Reason for discrepancy Iconsider ordering first)
. . . If no, which is
correct?
0 1 SSA abstract
0 2 Re abstract
0 3 Either
0 4 Neither
Oo1 Ordering SSA
def inition
O02 Ordering_
hospital list
Oo3 Ordering
completeness
O04 Ordering
judgment
Oo5 Ordering
other
O06 Ordering
dependent
~ ==
Write out the surgical procedures as they
appear on the Medicare claims form.
X. Status of Medical Record
0 1 Actual medical record
0 2 Microfilm of a complete record
3 3 Microfilm of an incompkete record
3 4 Other. specify
Oo7 Coding
clerical
008 Coding
completeness
~09 Coding
procedure
0 10 Coding
importance
0 7 1 Coding
judgment
0 12 Coding
other
54-55
Code the procedure first
listed on the Medicare-claims form:
Principal
17 1 1 1
Xl. Status of Claims Form
0 1 Actual claims form
0 2 lAiaofilm of claims form
~ ~] _
56~9
61
OCR for page 87
Appendix D
GENERAL INSTRUCTIONS FOR FIELD TEAM
Prior to the visit of the field team member, the medical record depart
ment and the billing office of each hospital will be sent a roster of
patient names, dates of birth, and Medicare claims numbers (hospital
insurance claims number) with associated admission and discharge dates
for the hospital episodes of interest. This list will be used by the
billing offices and medical record departments to locate the claims forms
and medical records in preparation for the research visit. A space will
be provided on the roster for medical record personnel to enter the med-
ical record number which corresponds with the Medicare claims number. A
copy of this roster of patient names and identifying information will also
be provided to the field team for each hospital visited. Upon entering
the the record department, the field team member should compare her mas-
ter list with the records which have been previously located by depart-
ment personnel in order to ascertain whether the required records are
available. At this time, any missing record should be requested from the
supervisor of the record department. If the record is not found, do not
replace it. Instead, return the blank Institute of Medicine re-abstract
form corresponding to the missing record, indicating that the record was
not available. The master list will be attached to a sealed envelope
containing the information provided by the Social Security Administration
(SSA). The envelope should not be opened until all records have been
abstracted.
Before beginning the actual abstracting process, the field team member
should discuss with the department supervisor appropriate items in the
"Medicare Processing Checklist." This will acquaint the field team member
with coding and billing practaces in each hospital which bear on the data
compiled from that hospital by the Social Security Administration. In
particular it will be important to ascertain how and in what form diag-
nostic and procedures information is provided to the billing office for
entry onto a Medicare claims form. Particular attention should be given
to how the hospital defined "primary diagnosis" or "surgical procedure"
for the purpose of completing the Medicare claims form during 1974. The
field team member should also review the format of the medical record
with the department supervisor to detect any unusual practices which
are unique to that hospital.
87
OCR for page 88
88
Appendix D
For each case to be abstracted, the field team member will be given an
Institute of Medicine re-abstracting form pre-coded with the patient's
hospital insurance claim number, date of birth, and date of discharge
for the hospital episode under study. A coder I.D., SSA provider number
(hospital Inn.), and sequential number will also be preprinted on the
form. No names will appear on the form. Once the Institute of Medicine
forms have been matched with the correct charts, the appropriate medical
record numbers must be entered on the Institute of Medicine's re-ab-
stracting form and later on the Social Security Administration's abstract
when the reconciliation process is carried out.
In completing the form, the field team should review the face sheet of
the medical record, the discharge summary, operative report, pathology
report, X-ray report (if appropriate), consultation notes, laboratory
reports, EKG (if appropriate), and diagnostic reports from such depart-
ments as physical medicine, physical rehabilitation and nuclear medicine.
The form will be used throughout the five steps of the re-abstracting
process, as follows:
1. The Institute of Medicine re-abstracting form is used to abstract
information from the medical record for the specified discharge date.
Column 1 should be completed for all items and all records to be
studied at a particular hospital. All records must be re-abstracted
before proceeding to the next step. The items to be re-abstracted and
definitions for each are given in the .'Specific Instructionst' below.
The field team member may make changes in the information recorded
in column 1 on the IOM re-abstract form during the initial re-abstract-
ing process. However, after column 1 of the IOM re-abstract is com-
pleted and the comparison and reconciliation with the SSA abstract
have begun no changes may be made in the re-abstracted information
in the column 1.
2. After all records in a given hospital have been re-abstracted, the
field team member should open the appropriate sealed envelope, which
will contain copies of the abstracts provided by the Social Security
Administration. Enter the medical record number onto each Social
Security Administration abstract. Compare information on each newly
completed Institute of Medicine re-abstract with the information
from the appropriate Social Security Administration abstract. In-
dicate whether or not the two abstracts agree by checking the appro-
priate "yes-no" response in column 2. If the items do not agree,
record the data provided by the Social Security Administration in
column 3, which is labeled "If no, enter information from abstract."
After all abstracts have been compared, proceed to the next step for
cases in which differences are found.
OCR for page 89
89
Appendix D
3. In each case, for those items in which there is a difference between
the information re-abstracted and that provided on the Social Security
Administration abstract, search the medical record to determine which
abstract is correct. The correct abstract should be indicated by
Checking one of the four alternatives in column 4: SSA abstract, re-
abstract either, or neither. "Re-abstract" refers specifically to the
Institute of Medicine re-abstract form. The "either" option should be
used only if, in the opinion of the field team, there is no obviously
"correct" response and either abstract is equally acceptable. "Neither"
means that both abstracts are in error.
4. After the correct abstract has been identified, refer to the item
definitions to determine the reasons for discrepancy (see "Specific
Instructions". In the event that both abstracts are in error (i.e.,
"neither'. was checked in the fourth column) the reason for discrepancy
should refer to the original abstract provided by the Social Security
Administration.
5. In column 2, which is labeled "Do abstract and re-abstract agree?"
(a) If yes has been checked, information will not be recorded
~ __
in columns 3, 4, 5, and 6, i.e., leave the rest of that
row BLANK.
(b) If no has been checked, information must be entered appropriately
_ . .
in columns 3, 4, 5, and 6.
The recording of information in column 6 is discussed in
item 7 below.
After all IOM re-abstracts have been compared to the Social Security
Administration abstracts, and all reconciliation steps have been
~ "' ' · . ! . ~ ~ _ ,
completed, including column 5, the field team member should review
all Institute of Medicine re-abstracts and separate them into
two categories:
(a)
(b)
Those in which no discrepancy on any item was found between the
Institute of Medicine re-abstract and the Social Security Admini-
stration abstract (i.e., in column 2, "yes" was checked for every
item) and those abstracts where there was a discrepancy (i.e.,
in column 2, 'No" was checked) but the correct data source checked
in column 3 was the Social Security Administration abstract (i.e.,
the field team member found herself in error).
Those in which one or more discrepancies were noted and where
the correct data source was determined as "re-abstracti', "either",
or "neither".
OCR for page 90
JO
Appendix D
7. The field team member should then go to the billing office. After
obtaining the remaining information about the manner in which that
particular facility completed its Medicare claims forms in 1974,
copies of Medicare claims forms (form 1453) should be obtained for
all the patient episodes under study. From the claims provided, the
field team should select out copies for all cases which fall into the
second category mentioned above (i.e. 6[b]~. For those items where
a discrepancy was found, the respective data frog the Medicare form
should be transferred onto the Institute of Medicine re-abstract in
column 6. For diagnoses and procedures, the narrative information
from the Medicare bill should be transferred verbatim onto the
Institute of Medicine re-abstract form. The first listed diagnosis
should then be coded in column 6 for diagnosis. Likewise, the first
listed procedure should be coded in column 6.
8. The following instructions refer to procedures for handling missing
data regardless of where the omission occurs (in the medical record,
Social Security Administration abstract, or copy of claims form).
(a) Admit and discharge date: if data are missing, enter 9's in
the appropriate boxes; be sure to fill each box.
(b) Sex: check box labeled "not recorded" if data are missing.
(c) Principal Diagnosis: by necessity, there will be no allowance
for missing data for principal diagnosis on either the SSA
abstract or the IOM re-abstract. However, 9's may be entered
in column 6 for missing principal diagnosis on the Medicare
claims form only. This would mean that the space for listing
principal diagnosis on the claims form was completely blank.
(d) Admitting Diagnosis: If an admitting diagnosis can not be
identified after following the specific instructions given
later, enter code 999.9 in the appropriate boxes.
(e) Procedures: X's should be entered if the Institute of Medicine
field team member finds that no procedures are significant
enough to warrant coding as "Principal Procedure't in column 1
at the bottom of Section IX. These X's will not indicate that
data are "missing", but rather that there were no procedures
worthy of coding. Zero's should be entered if the Institute of
Medicine field team member determines a principal procedure but
finds that there is no code in the OPT manual. For example,
physical therapy in some cases may be considered as a principal
procedure but does not have an assigned OPT code; in this case
the field team would then enter 0000 in the boxes for principal
procedure. The abstracts provided by the Social Security
Administration note "no procedures.' by "0000'.. When necessary,
these four zero's should be entered in column 3. (Of course,
OCR for page 91
91
Append ix D
column 3 is only filled out if the abstracts do not agree and
"no" has been checked in column 2; if "yes'. has been checked,
the re st of the row is to be le ft hi ank . ~
N : please refer to the Spec if ic Instructions for additional
guidance on completing this item.
9. If a Medicare claim form #1453 is needed but is not available, write
a note in the right hand margin of the re-abstracting form to indicate
such is the case.
OCR for page 92
OCR for page 93
Appendix D
SPECIFIC INSTRUCTIONS FOR IOM RE-ABSTRACTING FORM
In general, the Institute of Medicine field team should abstract medical
records using the definitions of the Uniform Hospital Discharge Data Set
(UHDDS); these definitions are attached, as well as Medicare definitions
for relevant items. The field team must be thoroughly familiar with both
sets of definitions before beginning the field work. Instances in which
the objectives of this study require deviation from the UHDDS definitions
are discussed below:
I. Identifying Information: with the exception of medical record num-
bers, all of the following identifying information will be pre-coded
on the Institute of Medicine re-abstracting form:
The Hospital Insurance Claim Number is the number assigned by the
Social Security Administration to a particular beneficiary. It is
used to assist in locating the appropriate medical record. Only
the number will be used, and in no case will the patient's name
be recorded on the Institute of Medicine re-abstract.
The SSA Provider Number is a six digit number assigned by the
Social Security Administration to identify the hospital.
The Coder Identification Number is a number assigned to each mem-
, At; .. .. . . .
her of the Institute of Medicine field team.
_ The Sequential Number is assigned to each hospital episode under
study by the Institute of Medicine for record keeping purposes.
o The Medical Record Number is the number assigned to the patient by
. ..... . . . · . .
the hospital and should be entered onto both the Social Security
Administration abstract and the Institute of Medicine re-abstract
by the field team as discussed in the General Instructions.
II. Instructions for Completing Column 1 on the Institute of Medicine
Re-abstracting form:
93
OCR for page 94
94
Appendix D
Admission Date and Discharge Date definitions are the same as those
of UHDDS except that the hour of admission or discharge will not be
recorded. For example, October 1, 1974 should be coded:
M M D D Y Y
/1 0/ /0 1/ /7 4/
Note that the boxes for "day" have been darkened on the re-ab-
stracting form. This is to emphasize that the appropriate record-
ing sequency is month, day, year.
Sex is to be coded as male or female. The response of not recorded
~ .
is reserved for missing data.
· Admitting Diagnosis. The field team member should search the face
sheet, emergency room, history and physical reports, and admission
notes and write in the diagnoses which appear in these parts of the
record. The part of the record from which each diagnosis was ab-
stracted should be indicated as follows:
ER = Emergency Room Reports
HR = Reports of History and Physical
A = Admission Notes
After reviewing these diagnoses obtained only from those portions
of the record specified, the field team member should determine
an admitting diagnosis and place an "A" next to the appropriate
diagnosis. A refined diagnosis should not be be abstracted unless
it is absolutely clear that this more precise diagnosis was known
at admission or soon thereafter. The ICDA-8 code (adapted by the
Social Security Administration) for the admitting diagnosis should
be inserted in the boxes in the lower portion of Section IV.
.
Principal Diagnosis. After determining an admitting diagnosis,
the field team member should continue searching the medical record,
writing additional diagnoses in the space provided on the Institute
of Medicine re-abstracting form. The part of the record from which
each diagnosis was abstracted should be indicated as follows:
F = Face Sheet
D = Discharge Summary
C = Consultation
0 = Operative Report
P = Pathology Report
R = Reports, such as EKG, EEG, X-ray, or other
diagnostic laboratory reports
OCR for page 95
95
Appendix D
When the entire medical record has been searched and the important
diagnoses entered on the Institute of Medicine re-abstracting form,
the field team member should then review the diagnoses listed and
determine a principal diagnosis using the UHDDS definition (i.e.,
that condition established after study to be chiefly responsible
for occasioning the admission of the patient to the hosital for
care). A "P" should be placed in the second column next to the
appropriate diagnosis. The ICDA-8 code (adapted by the Social
Security Administration) should be inserted in the appropriate
boxes in the lower portion of Section V and also in the first
column of Section VII.
.
~ ·~ ~ ·~ · ~ ~ ~ ~~d ~ ~: ~ ~ snag s. After coding an
admitting and principal diagnosis, the field team member should
compare them and check in the appropriate place in Section VI
whether they agree. If they do not agree, then she will check
the reason which could best account for the difference. These
reasons include: completeness, coding refinement, and '.other"
which are explained later.
· Additional Diagnoses. If more than one diagnosis was abstracted
. . . . ... . . . . .. ... .
in Section IV or V, and in the field team's judgment could be
considered as an 'additional diagnosis", check the appropriate
code in column 1 of Section VIII to indicate the presence or
absence of additional diagnoses.
Guidelines for determining whether to count a diagnosis as "addi-
tional include:
a) Any diagnosis clearly stated as a diagnosis by the physician
on face sheet or discharge summary. Do not include "rule out"
unless it is actually a "viable", "probable", or 'possible",
still active and of some significance, not just a confirmed
diagnosis. Do not count .`history of" etc., that are sometimes
recorded but are not clinically significant for this stay.
b) Any diagnosis clearly present when reviewing a chart including
surgical diagnosis or consultant's diagnosis when definitive.
c) Pathology diagnosis when it fits that mentioned immediately
above; do not count if they are not clinically significant
or only of histologic interest, e.g., chronic cervicitis,
when not a major problem.
d) X-ray diagnosis when clearly substantiated and of some sig-
nificance: a fracture of a bone with surgery or treatment
would clearly be included, whereas a slight degree of osteo-
arthritis for which a patient was not treated and noted only
OCR for page 96
96
Appendix D
· Procedures
as an observation would not. Omit if only of radiologic
interest or indicated as "consistent with" but not further
substantiated by other internal evidence.
e) Diagnoses inferred from physical findings or laboratory find-
ings should be included only if obviously of clinical import-
ance or otherwise substantiated in the record.
There are three reasons for discrepancy for this item: com-
pleteness, hospital definition, and importance, as discussed
later.
All procedures are to be written on the re-abstracting form. In
addition, the portion of the record from which each procedure was
abstracted should be indicated in column 1 according to the symbols
used in abstracting diagnoses. In column 2, place a "P'. next to
the procedure which is the principal procedure according to the
UHDDS definition. The field team will have to exercise some dis-
cretion in assigning a principal procedure when only a minor one--
such as "manual arts therapy"--has been noted in the chart. Do
be overzealous in coding, but on the other hand procedures of
clear significance should definitely be recorded.
Enter the appropriate code for the principal procedure in the boxes
provided, in the first column of the lower portion of Section IX.
The Current Procedural Terminology (CPT) nomenclature should be
used. When the field team determines no procedures significant
enough to warrant coding, X's should be entered in all the appro-
priate boxes; if there is no CPT code for a principal procedure,
identified by the field team, 0000 should be entered. The General
Instructions provide further information for coding missing data.
.
.
Status of Medical Record
In Section X the field team member should check the status which
best describes the physical form and completion status of the med-
cal records which were abstracted for the study by indicating if
they used a microfilm of a complete record, a microfibm of an in-
complete record or an actual completed medical record.
Status of Claims Form
In section XI the field team member should check the status which
bests describes the physical form of the Medicare claims form #1453
by indicating if the actual claims form or microfilm was used.
OCR for page 97
97
III Reasons for Discrepancy
Appendix D
· Reasons for Discrepancies in Admission Date, Discharge date and Sex
. . .. .... ..
Two reasons are to be used to explain discrepancies between the
Institute of Medicine re-abstract and the Social Security Admin-
istration abstract for admission and discharge dates and sex:
a) Clerical: Discrepancy attributable to human error, mistakes
. . . ..
Of a particular clerk, errors in transcribing number, etc.
(Example: obvious transposing of numbers on admission or
discharge date.)
b) Completeness: Incomplete or inaccurate information on the
abstract or re-abstract due to an incomplete review of the
chart (Example: item missing from the admitting sheet, but
clearly stated in the discharge summary.)
Reasons for Discrepancy in Comparing Admitting and Principal
Diagnosis
c)
a) Completeness Discrepancy due an incomplete review of the
of the emergency room report, the history and physical notes,
or the admission notes. (Example: the field team may assign
an admitting diagnosis of diabetes, having overlooked the
admission notes or ER reports which indicated that an open
wound infection would have been the more appropriate admitt-
ing diagnosis.)
b) Coding Refinement: Discrepancy due to a difference in level
.. . . . . .
Of refinement between the codes for admitting and principal
diagnosis. For example, the admitting diagnosis may be 486.0
(pneumonia) while the principal ("final'') diagnosis would be
the more refined code 481.0 (pneumococcal pneumonia). This
is not really an error, but more a reason which accounts for
the fact that admitting diagnoses are often by necessity more
general than discharge diagnoses.
Investigation: Discrepancy resulting from an admitting diag-
~ . . .. .
nosis being assigned on a preliminary finding or symptom and
upon further medical investigation, a more precise - and quite
different - diagnosis was determined. For example, a patient
may be admitted with headache (ICDA code 791) and after further
testing and investigation, it turns out to be due to hypogly-
caemia (ICDA code 251~.
OCR for page 98
98
Appendix D
d) Other: Discrepancy which cannot be explained by any of the
above. The field team member should make a brief note to
explain the problem on the back of the re-abstracting form.
· Reasons for Discrepancy for Diagnosis and Procedure
There are two general categories into which reasons for discrepancy
for diagnosis and procedure are grouped: ordering and coding.
a) An ordering discrepancy will be used to reflect an inconsist-
-
ency between the SSA abstract and the TOM re-abstract which
stems from uncertainty over whether a diagnosis or procedure
should be regarded as the 'principal" diagnosis or procedure,
in accord with UHDDS definitions. The possibility of an order-
ing discrepancy should be considered and eliminated before the
possibility of a coding discrepancy is entertained. Defini-
tions of specific types of ordering discrepancies follows:
1. Ordering--Definition: Discrepancy in ordering of principal
diagnosis and/or procedure because of a difference between
the UHDDS definition and that required by the Medicare claims
form. (Example: a patient is admitted for an open fracture
reduction and, while on the operating table suffers an acute
MI which keeps him in the hospital three months. Using the
UHDDS definition, fracture reduction would be chosen as the
principal diagnosis because, as the definition requires,
fracture is the diagnosis explaining cause of admission.
If the definition in the "Medicare Hospital Manual" for
principal diagnosis is used, however, the code might be
AMI. Medicare states: "the primary diagnosis is the diag-
nosis or the illness or condition which was the primary
reason for the patient's hospitalization"--(in other words,
the most serious diagnosis.) A fuller listing of the
Medicare definitions for diagnoses and procedures appears
at the end of these instructions with the UHDDS definitions.
In order to use this reason, of course, the field team must
first ascertain that the hospital in question carefully
and consistently used the Medicare definitions in complet-
ing the claims forms in 1974.
2. Ordering--Hospital List: Discrepancy in ordering of prin-
edure which stems for a routine
hospital practice (in 1974) of choosing the first listed
diagnosis or procedure on the face sheet as principal.
For example, if this practice was followed, by a hospital,
chronic ischemic heart disease may be chosen as a princi-
pal diagnosis because it was the first listed on the face
sheet while congestive heart failure would have been the
principal diagnosis if UHDDS definitions were used.
OCR for page 99
99
Appendix D
3. O_dering--Completeness: Discrepancy in choice of princi-
pai diagnosis and/or procedure caused by assigning a code
based on an incomplete review of the medical record. For
example, the principal diagnoses selected by TOM and SSA
refer to different diseases, each of which the patient had
during the hospital episode under question. However, if
the chart had been searched more thoroughly, it would have
been clear that one, rather than the other, was the proper
principal diagnosis according to UHDDS. More specifically,
SSA coded hydrocephalus as principal diagnosis and IOM, a
decubitus ulcer. The patient had both problems, but a
careful review of the chart would clearly indicate that
decubitus ulcer was the true principal diagnosis.
Ordering--Judgment: Discrepancy in selection of principal
. . .
diagnoses or procedure which represents an honest d~ffer-
ence of opinion in interpreting the medical record, pri-
marily in determining which of several diagnoses is prin-
cipal. One example of this might be a record in which
a patient had diabetes and glaucoma and there was suffi-
cient documentation in the record to decide that either
diagnois would conform to the UHDDS definition for prin-
cipal diagnosis. Similarly, a record may indicate car-
cinoma of several sites and may not be well documented
so as to clearly determine a principal diagnosis using
the UHDDS definition.
5. Ordering--Other: A discrepancy in ordering of principal
. . . . .. . ..
diagnosis and/or procedure other than the above. If this
reason is used, please write a note to briefly describe
the discrepancy.
6.
b)
Ordering--Dependent: This reason applies only to the
coding of procedure.
. , .
This reason will be used to reflect a discrepancy which
results from a prior discrepancy in a related item. Usually,
this situation will occur only when an earlier discrepancy
in selection of the principal diagnosis results in a depen-
dent discrepancy in selecting the principal procedure.
A coding discrepancy applies only to the actual coding of the
principal diagnosis and the principal procedure after the pos-
sibility of an ordering discrepancy has been eliminated. In
other words, there is general agreement on what the principal
diagnosis or procedure should be, but the codes differ for one
of the following reasons:
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Append ix D
1. Coding--Clerical: Discrepancy caused by transposing diag-
~ers or using non-existent codes, i .e .,
there was apparent agreement between the Institute of
Medicine and the Social Security Administration on which
diagnosis or procedure is primary, but the difference lies
in a clerical mistake in inserting the code numbers.
Coding--completeness: Discrepancy which may be caused by
antic or procedure code based on an ~ncom-
plete review of the medical record, i.e. coding a diagnosis
with a .9 fourth digit ~ indicating "not otherwise specified")
when a more careful review of the chart would have yielded
a
more specific fourth digit code.
Coding--procedural: Discrepancy caused by routine and sys-
Misunderstanding of the coding system,
resulting in a discrepancy. (Examples: rel lance on index
without reference to tabular listings, failure to heed in-
clusion and/or exclusion advice from tabular listings).
Codina--Importance. (This reason ~ ~
7~—=~_ s of opinion
over how significant a procedure must be to be coded, i .e .,
SSA has coded a diagnostic procedure as the principal pro-
cedure while the ION re-abstract lists no principal pro-
cedure. Because it may be unclear whether a given diag-
nostic procedure "qualifies" as a principal procedure, this
reason would be selected to explain the discrepancy.
Coding--Judgment: Discrepancy caused by ab sence of com-
plete word-for-word correspondence between the recording of
the diagnosis or procedure in the record and the wording
in the coding manual s . Mat is, an honest difference of
opinion over the correct code when it is not clear from the
coding manual what the numbers should be. (Example: diag-
nosis listed as recurrent and it is unclear whether ''acute"
or '"chronic" is actually the more appropriate qualifier
for coding purposes and these are the only two options
available . ~
6 . Coding--Other :---Discrepancy in coding not due to any of
the above. In particular this option would be used to ~n-
dicate a discrepancy resulting from SSA's use of 0000 or
6040 to code procedure when the TOM has used ~ valid code,
XXXX or 0000. The use of these codes is explained on page
11.
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· Reasons for Discrepancy on Presence of Additional Diagnoses
_ .
2.
Appendix D
Completeness: Discrepancies in interpreting the presence or
. . . . . . . . .
absence of additional diagnoses which could be the result of
an incomplete review of the medical record (to be used only
in hospitals which routinely note additional diagnoses on
Medicare Claims form, as revealed by the checklist).
Hospital Definition: Discrepancies which result from a hos-
pital policy. For example, some hospitals may routinely enter
only one principal diagnosis on the Medicare Claims form and
therefore, by definition, no additional diagnoses would appear
on the SSA abstract.
3. Importance: Discrepancy which may be due to the guidelines
specified above for the field team. For example, osteo-
arthritis may be listed as an additional diagnosis in the
medical record and the Medicare Claims form might indicate the
presence of an additional diagnosis. However, if it was noted
in the record only as an observation, then, using the IOM guide-
lines, it would not be counted as an additional diagnosis.
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Appendix D
UHDDS Definitions
The Institute of Medicine's field team member will use the following
UHDDS definitions for diagnoses and procedures during the re-abstract-
ing and reconciliation process. The definition for "other diagnoses"
will be used in conjunction with the guidelines listed in the Specific
Instructions for determining whether to count a diagnosis as additional.
Specific UHDDS Definitions follow: 1/
o Principal Diagnosis:
"The condition established after study to be chiefly respon-
sible for occasioning the admission of the patient to the hos-
pital for care."
o Other Diagnoses:
"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 relate to an earlier episode-which have
no bearing on this hospital stay are to be excluded."
o Procedures:
"All procedures performed in operating rooms are to be reported...
In addition to these procedures, all other significant procedures
are to be recorded. A significant procedure is one which carries
an operative or anesthetic risk or requires highly trained per-
sonnel or special facilities or equipment. Some examples of such
procedures are cardiocatheterization, angiography, endoscopy, and
super-voltage radiation therapy.
When more than one procedure is recorded the principal procedure
is to be designated. In determining which of several procedures
is the principal, the following criteria apply:
(1) The principal procedure is one which was performed for defin-
itive treatment rather than one performed for diagnostic or
exploratory purposes, or was necessary to take care of a
complication.
(2) The principal procedure is that procedure most related to the
principal diagnosis."
1
Uniform Hospital Abstract: Minimum Basic Data Set. National Center
for Health Statistics, A Report of the United States National Committee
on Vital and Health Statistics, Series 4, Number 14, December 1972.
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Medicare Definitions
Appendix D
The Institute of Medicine's field team members should familiarize them-
selves with definitions for diagnoses and procedures given in the "Medi-
care Hospital Manual." These definitions listed below, must be considered
during the reconciliation process for diagnoses and procedures, particularly
in assessing whether a discrepancy in the ordering of a principal diag-
nosis or procedure may be due to a difference between the UHDDS definition
and that required by Medicare. If such is the case, the correct reason
for discrepancy to be chosen should be "ordering definition" ad explained
on page six of the Specific Instructions.
Medicare definitions for diagnosis and procedure follow: 2/
t
Primary Diagnosis
"The primary diagnosis... is defined as the diagnosis of the
illness or condition which was the primary reason for the patient's
hospitalization."
Surgical Procedures
-
I.Surgical procedures should be specified using a recognized
nomenclature... For the purpose of completing Medicare claims
form 1453, surgery includes incision, excision, amputation,
introduction, and escopy, repair, destruction, suture and
manipulations... List first those procedures related to the
primary diagnosis."
Medicare Coding of Procedures
The Social Security Administration has two unique codes to indicate prob-
-
lems in coding procedures. They include:
· 0000 - This four zero code is used by SSA to note that 1) the
space for writing in a procedure on the claims form was blank;
or 2) a procedure was recorded for which there is no OPT code;
or 3) an ineligible term was entered in the space (such as a
date or sex designation).
· 6040 - this code is used to note that an illegible procedure
was listed on the claims 1453 and that therefore no procedure
code could be selected.
Medicare Hospital Manual, U.S. Department of Health, Education, and
Welfare, HIM Pubn. 10- (6-66), Reprint, August 1975.
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Append ix D
Specific guidelines for resolving problems generated by the 0000 and 6040
codes inc. rude:
1.
When a field team member locates a procedure in the chart and
wishes to code it, but there is no OPT code for it, enter 0000
in columum 1. When comparing this with the SSA abstract which
also has 0000 listed in the procedures space, note in
column 2 that the abstracts "agree."
2. When the field team member reviews a chart and decides that
there is no procedure significant enough to be coded, write
XXXX in column 1. As discussed above, SSA enters
the procedure box on the claims form is empty. Theretore, tt
the IOM re-abstract has XXXX, and the SSA abstract has 0000,
mark in column 2 that the abstract agree. The characters are
different in the example given here (X's and 0's), but they
refer to the same fact, i.e., no procedure to be coded - and
thus the abstracts do agree.
OO00 when
3. If the field team member codes a procedure and the SSA abstract
says 6040 (illegible code), note that the abstracts disagree,
the IOM re-abstract is correct (column 4) and use CODING OTHER
as the reason for discrepancy. Similarly if the field team mem-
ber has coded XXXX or 0000 for principal procedure and SSA has
6040 the abstracts do not agree, the IOM abstract is correct,
and "coding other" is the reason for discrepancy.
Representative terms from entire chapter:
medical record
