View source for CCI Collection

This article provides general information about collecting and coding a [[CCI Procedure]].  

They are entered in [[CCMDB.mdb]] in the [[Patient viewer tab CCI]] on the [[Patient viewer tab CCI]].

There are some [[ICD10 Diagnoses and CCI Codes that need to be coded together]]. For background information, see [[CCI]] and [[Reasoning around moving to CCI and our subset of it]].

== Collection instructions ==

=== Determining if the procedure you found is one we collect ===
*There are THREE subsets of procedures we '''will'' code
**Procedures done outside the unit
**Procedures done on the unit including an endoscope
**A select group of other procedures done on the unit.

==== (A) Procedures done outside the unit ====
Include ''all '''[[List of CCI procedures we don't code|codable]]''' procedures'' that meet the definition of one of the [[Px Type]]s that are done '''outside the patient’s unit'''.

==== (B) Procedures done on the unit (endoscope or non-therapeutic) ====
*This includes both diagnostic and therapeutic procedures done with an endoscope -- and that scope may be inserted through an oriface, incision or wound.
*Includes '''all of the following '''[[List of CCI procedures we don't code|codable]]''' procedures''' done on the unit:

=== (C) Other on-unit procedures ===
*(b) all [[List of CCI procedures we don't code|codable]] '''[[Diagnostic Procedure]]s'''
*(c) all [[List of CCI procedures we don't code|codable]] '''[[Imaging Procedure]]s'''
*(d) all [[List of CCI procedures we don't code|codable]] '''[[Obstetric Procedure]]s'''
*(d) all [[List of CCI procedures we don't code|codable]] '''[[Miscellaneous Procedure]]s'''

==== [[CCI Procedures coded once per ward admission]] ====
Some procedures are only coded the first time they happen. See [[CCI Procedures coded once per ward admission]].

=== Don't code sub-procedures that are part of a larger procedure ===
Do not code a procedure that is part of a "Bigger" procedure already coded. 
'''Example:''' In the course of many or most CABG surgeries, there is placement of chest tubes, pacer wires, and vein harvest, but do NOT code those procedures separately, since they are "included" in the CABG code.

=== Before You Decide to NOT Code a Procedure ===
*We're not looking to code procedures that not either: (a) on the picklist, or (b) able to be constructed from it's components [e.g. a body part, and what was done to that body part].
*The main issue here is that among the lists "what was done", we haven't included EVERY possibility. 
**For example, in the Imaging Procedures, besides some plain X-rays contained in that picklist, the "what type of imaging study was done" does NOT include plain x-rays.  Thus we're not enabling creation of a plain X-ray of other body part other than those contained in the picklist.
**Similarly, for the Therapeutic Procedures, there is a list of approximately 30 items of "what was done" to the chosen body part. So some items of "what was done" are not available and you won't be able to code such procedures.  
***'''BUT, before you decide this is the case, you will need to become very familiar with the descriptions of EACH of the "what was done" items that ARE available'''.  For example the item '''[[Bypass]]''' includes creating a ostomy (which includes a colostomy and even a tracheostomy).
****See '''[[CCI component 2 codes - what was done]]'''

=== [[Aborted Procedure]] ===
*See [[Aborted Procedure]] for how to code

== Selecting and entering [[CCI]] procedure in [[CCMDB]] ==
Follow these steps, in this order: 
# for every procedure: 
## check if the procedure is listed in the [[CCI Picklist]] in the [[L_CCI_Picklist subform]] which is the top half of the CCI screen. Select from drop down list. 
## if '''not''' available in CCI picklist, enter it in the [[CCI Component]] in the [[L_CCI_Component subform]] which is the bottom half of the CCI screen. 
##* pick the left column, [[CCI component 1 codes - what organ was something done to]].
##** if there are too many and you only want to see e.g. the therapeutic ones and not the imaging ones, use the [[L_CCI_Component_subform#CCI_Chooser (the "?" button)]]. In the form it opens you can filter by the [[CCI Category]].
##* in the column on the right, pick the [[CCI component 2 codes - what was done]].
## whether CCI picklist or CCI component, 
### enter a [[Px_Type]] - "admit" ([[Admit Procedure]]) or "acquired" ([[Acquired Procedure]])
### enter a [[Px_Date]] - Date of procedure '''for acquired px only'''
### enter a [[Px_Count]] - the number of '''separate''' times it was done''' '''''on a given day

=== Repeated procedures ===
If a procedure is done repeatedly '''on the same day''', only enter it once but count it in [[Px_Count]]. 

Procedures done on a '''different''' day should be entered again with a different date. This should be really quick by using the "duplicate" button.

=== Related Imaging, Diagnostic and Therapeutic procedures performed at the same time ===
Some intervention are both diagnostic/imaging and therapeutic. For those situations, only code the therapeutic part.

For endoscopic inspection/explorations, code only the '''"furthest/deepest"''' area assessed.  

Examples: 
* for a [[Coronary angiogram (diagnostic cardiac catheterization)]] where [[Coronary angioplasty with stenting]] happens in the same sitting, only code the [[Coronary angioplasty with stenting]].
* if a tissue [[Biopsy (non-endoscopic)]]/[[Biopsy (endoscopic)]] is done as part of an invasive [[Inspection, Exploration (non-endoscopic)]]/[[Inspection, Exploration (endoscopic)]] code only the [[Biopsy (non-endoscopic)]]/[[Biopsy (endoscopic)]].
* If a CT is done on the abdomen, chest and pelvis, enter 3 entries in the component area?

=== We are not tracking all possible procedures ===
We are not tracking all possible procedures; see [[Reasoning around moving to CCI and our subset of it#Why do we not include the entire set of CCI codes]] and [[List of CCI procedures we don't code]] for more info.

=== No Procedures Performed ===
If no procedures were performed '''enter [[No procedure performed]] as an [[Admit Procedure]] into the [[CCI Picklist]]''', the top of the tab. Entering this will mean at least one CCI entry is present when [[Query check CCI must have entry]] checks that entering procedures was not just forgotten.

=== Procedures not coded ===
See [[List of CCI procedures we don't code]]

==Data Integrity Checks ==
{{#ask: [[DICSummary::+]] [[Category: CCI Px check]]
|?DICSummary = summary
|?DICStatus = implementation status
|sort=DICStatus, DICSummary
|default=none found
|format=broadtable
|limit=100
|link=all
|headers=show}}

== Related Articles ==
{{Related Articles}}

== related literature ==
[https://secure.cihi.ca/free_products/Coding%20standard_EN_web.pdf CIHI.ca coding standard CCI]



[[category: ICD10/CCI Conversion]]
[[Category: CCI| *]]