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.
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