Purpose
In this assignment, you will gain hands-on experience working with the Uniform Hospital Discharge Data Set (UHDDS) in the EHRGo platform. UHDDS is the federally mandated standard for collecting data on hospital discharges for Medicare and Medicaid programs. You will review a patient chart, abstract key data elements, and analyze how coding accuracy and compliance affect billing, reimbursement, and fraud prevention.
Instructions
1. Access the Assignment
Log in to EHRGo using the access code provided by your instructor.
Under Activities, locate UHDDS and the EHR (Baccalaureate).
Click Launch EHR to access the patient chart.
2. Review the Patient Chart
Examine the de-identified inpatient record carefully.
Pay attention to all UHDDS-required data elements:
Person/Enrollment Data: Demographics, insurance coverage, identifiers
Encounter Data: Admission/discharge dates, principal diagnosis, procedures, attending provider, payment source
3. Abstract UHDDS Data Elements
Using the provided worksheet:
Record all required data elements accurately.
Identify the principal diagnosis and principal procedure following UHDDS definitions.
Ensure coding selections align with compliance and reporting standards.
4. Respond to Critical Thinking Questions
In the same worksheet, answer the following in 4–6 sentences each:
Why is UHDDS standardization important for Medicare and Medicaid reimbursement?
How does coding accuracy affect compliance, audit readiness, and fraud prevention?
What are the potential consequences of incomplete or inaccurate UHDDS data on reimbursement and compliance programs?
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