Reliability of Medicare Hospital Discharge Records Report of a Study (1977) / Chapter Skim
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Appendix D IOM Re-abstracting Form, General Instructions for Field Team, and Specific Instructions for IOM Re-abstracting Form
Appendix D IOM Re-abstracting Form, General Instructions for Field Team, and Specific Instructions for IOM Re-abstracting Form
Pages 85-104
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From page 85... ...
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.
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From page 86... ...
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.
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From page 87... ...
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 diagnostic and procedures information is provided to the billing office for entry onto a Medicare claims form.
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From page 88... ...
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-abstracting 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)
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From page 89... ...
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)
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From page 90... ...
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)
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From page 91... ...
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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From page 93... ...
Identifying Information: with the exception of medical record numbers, 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.
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From page 94... ...
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.
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From page 95... ...
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.
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From page 96... ...
. 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 medcal records which were abstracted for the study by indicating if they used a microfilm of a complete record, a microfibm of an incomplete record or an actual completed medical record.
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From page 97... ...
.. Two reasons are to be used to explain discrepancies between the Institute of Medicine re-abstract and the Social Security Administration abstract for admission and discharge dates and sex: a)
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From page 98... ...
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.
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From page 99... ...
Usually, this situation will occur only when an earlier discrepancy in selection of the principal diagnosis results in a dependent 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 possibility of an ordering discrepancy has been eliminated.
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From page 100... ...
Coding -- completeness: Discrepancy which may be caused by antic or procedure code based on an ~ncomplete review of the medical record, i.e. coding a diagnosis with a .9 fourth digit ~ indicating "not otherwise specified")
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From page 101... ...
. 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)
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From page 102... ...
Specific UHDDS Definitions follow: 1/ o Principal Diagnosis: "The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital 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...
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From page 103... ...
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 problems in coding procedures.
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From page 104... ...
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.
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