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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 ....

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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

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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

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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.

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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".

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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,

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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.

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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

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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

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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

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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.

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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~.

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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.

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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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100 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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101 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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102 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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103 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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104 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.