Certified Inpatient Coding (CIC) Practice Exam

Which data element is NOT part of the Uniform Hospital Discharge Data Set (UHDDS)?

1. Principal diagnosis

2. Admission date

3. Admitting diagnosis

4. Attending physician

The correct answer is: Admitting diagnosis

The Uniform Hospital Discharge Data Set (UHDDS) is designed to standardize the collection of data for hospital discharges. It includes key data elements that are critical for various analyses, including operational, clinical, and financial aspects of healthcare. The principal diagnosis is a required data element in the UHDDS, as it identifies the main reason for the patient’s admission. The admission date is also crucial, as it indicates when the patient was admitted for treatment. The attending physician is included because this element identifies the primary physician responsible for the patient's care during the hospital stay. In contrast, while the admitting diagnosis is significant in the clinical context, it is not explicitly listed as one of the required elements in the UHDDS. Instead, it is a broader term that may describe the condition leading to admission but doesn't serve the same role in the discharge dataset. By understanding this distinction, you can see why the admitting diagnosis is not part of the UHDDS, further emphasizing the focus on elements directly tied to the discharge process rather than those that pertain to the admission phase.