CCI Collection: Difference between revisions

(26 intermediate revisions by 3 users not shown)

Line 1:

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~~]].

They are entered in [[CCMDB.accdb]] in the [[Patient Viewer Tab CCI_Pick]] and [[Patient Viewer Tab CCI_Comp]] on the [[Patient Viewer]].

~~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]].

For background information, see [[CCI]] and [[Reasoning around moving to CCI and our subset of it]].

== Collection instructions ==

===Start Date: Jan 1, 2019 ===

=== 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]]; the component on the right has to be of the same ''diagnostic / therapeutic / imaging'' kind as the component 1 - if you try to mix types you will get an error.

## 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

==== productivity features ====

To reduce clicks to enter same Picklist entries for additional days, there are some extra buttons:

* "x2" will duplicate this line with the next date

** "+" and "-" will up or down the date by one day, to make the copy more useful

* [[Blue button in CCI Picklist]] will fill a range of dates

== Collection modes ==

*We code CCI procedures in 5 different [[CCI Collection Mode]]''':

*We code CCI procedures in 5 different [[CCI Collection Mode]]s''':

Line 36:

Line 58:

}} }}

=== ~~Selecting and entering [[CCI]] procedure in [[CCMDB]]~~ ===

== Special Cases ==

~~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~~

=== No Procedures Performed ===

If no procedures were performed '''enter [[No procedure performed]] as an [[Admit Procedure]] with a [[Px Count]] of 1 into the [[CCI Picklist]]''', the top of the tab. Do not enter any procedrues into the CCI Component section, ie leave it as "[[No procedure entered]]". 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.

=== Moved patients ===

*There are important issues/rules for admit procedure coding when a patient is being transferred from one unit/ward to another unit/ward -- and this is even more complicated if in between leaving one unit/ward and arriving on another unit/ward, the patient stops in a procedure area and gets one or more procedures.

*Here are the guidelines for these situations:

**(i) Transfer from collecting location A to collecting location B without any stop in between where procedures might occur -- all procedures done before leaving location A will be collected by location A only.

**(ii) Transfer from collecting location A to collecting location B WITH a stop in between where procedures occur -- all procedures done before leaving location A will be collected by location A only, while procedures done at the stop in between will be coded by location B only.

**(iii) Transfer from noncollecting location A (which includes ED) to collecting location B without any stop in between where procedures might occur -- any qualifying admit procedures done before leaving location A will be collected by location B

**(iv) Transfer from noncollecting location A (which included ED) to collecting location B WITH a stop in between where procedures occur -- all procedures done before leaving location A or during the stop in between will be coded by location B only.

=== Procedures we don't code ===

Line 59:

Line 77:

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.

~~{{DA|not just deepest - these may need to change, and likely be combined.~~

=== 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.

*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.

'''Example:''' In the course of many or most CABG surgeries, there is placement (or replacement) of chest tubes, pacer wires, arterial lines, central lines, and vein harvest, but do NOT code those procedures separately, since they are "included" in the CABG code.

*On the other hand, things done in OR that are NOT part of the standard procedure (e.g. for someone coming out from OR after CABG who now has ECMO, Swan-Ganz, IABP), you SHOULD code these as [[Admit Procedure]]).

=== 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~~.

*When at the same sitting both diagnostic and therapeutic procedures are done, then CODE THEM BOTH

{{ex|* a cardiac cath is done and then a stent is placed -- code the diagnostic cath and the therapeutic stenting.

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

* for an [[Angiogram, coronary (diagnostic cardiac catheterization)]] where [[Angioplasty, coronary (with stenting)]] happens in the same sitting, code both}}

* if a tissue [[Biopsy (non-endoscopic)]]/[[Biopsy (endoscopic)]] is done as part of an invasive [[Inspection, Exploration (non-endoscopic)]]/[[Inspection, Exploration (endoscopic)]] code both

~~Examples:~~

*When multiple procedures are done at one sitting, code them all

* for a [[Angiogram, coronary (diagnostic cardiac catheterization)]] where [[Angioplasty, coronary (with stenting)]] happens in the same sitting, ~~only~~ code ~~the [[Angioplasty, coronary (with stenting)]].~~

{{Ex|if a CT of chest, abdomen and pelvis is done, code them all}}

* 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)]].~~

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

* If a CT is done ~~on the abdomen~~, ~~chest and pelvis~~, ~~enter 3 entries in~~ the ~~component~~ area?

}}

=== [[Aborted Procedure]] ===

Line 100:

Line 116:

== related literature ==

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

[https://secure.cihi.ca/free_products/CodingStandards_v2018_EN.pdf CIHI.ca coding standard CCI]

@@ Line 1: / Line 1: @@
 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]].
+They are entered in [[CCMDB.accdb]] in the [[Patient Viewer Tab CCI_Pick]] and [[Patient Viewer Tab CCI_Comp]] on the [[Patient Viewer]].
-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]].
+For background information, see [[CCI]] and [[Reasoning around moving to CCI and our subset of it]].
 == Collection instructions ==
+===Start Date: Jan 1, 2019 ===
+=== 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]]; the component on the right has to be of the same ''diagnostic / therapeutic / imaging'' kind as the component 1 - if you try to mix types you will get an error.
+## 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
+==== productivity features ====
+To reduce clicks to enter same Picklist entries for additional days, there are some extra buttons:
+* "x2" will duplicate this line with the next date
+** "+" and "-" will up or down the date by one day, to make the copy more useful
+* [[Blue button in CCI Picklist]] will fill a range of dates
+== Collection modes ==
 <!--As discussed [[Task_Team_Meeting_-_Rolling_Agenda_and_Minutes#ICU_Database_Task_Group_Meeting_.E2.80.93_October_31.2C_2018]] -->
-*We code CCI procedures in 5 different [[CCI Collection Mode]]''':
+*We code CCI procedures in 5 different [[CCI Collection Mode]]s''':
 {{:CCI collect each}}
 {{:CCI collect count each}}
@@ Line 36: / Line 58: @@
 }} }}
-=== Selecting and entering [[CCI]] procedure in [[CCMDB]] ===
+== Special Cases ==
-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
 === No Procedures Performed ===
 If no procedures were performed '''enter [[No procedure performed]] as an [[Admit Procedure]] with a [[Px Count]] of 1 into the [[CCI Picklist]]''', the top of the tab. Do not enter any procedrues into the CCI Component section, ie leave it as "[[No procedure entered]]". 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.
+=== Moved patients ===
+*There are important issues/rules for admit procedure coding when a patient is being transferred from one unit/ward to another unit/ward -- and this is even more complicated if in between leaving one unit/ward and arriving on another unit/ward, the patient stops in a procedure area and gets one or more procedures.
+*Here are the guidelines for these situations:
+**(i) Transfer from collecting location A to collecting location B without any stop in between where procedures might occur -- all procedures done before leaving location A will be collected by location A only.
+**(ii) Transfer from collecting location A to collecting location B WITH a stop in between where procedures occur -- all procedures done before leaving location A will be collected by location A only, while procedures done at the stop in between will be coded by location B only.
+**(iii) Transfer from noncollecting location A (which includes ED) to collecting location B without any stop in between where procedures might occur -- any qualifying admit procedures done before leaving location A will be collected by location B
+**(iv) Transfer from noncollecting location A (which included ED) to collecting location B WITH a stop in between where procedures occur -- all procedures done before leaving location A or during the stop in between will be coded by location B only.
 === Procedures we don't code ===
@@ Line 59: / Line 77: @@
 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.
-{{DA|not just deepest - these may need to change, and likely be combined.
 === 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.
+*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.
+'''Example:''' In the course of many or most CABG surgeries, there is placement (or replacement) of chest tubes, pacer wires, arterial lines, central lines, and vein harvest, but do NOT code those procedures separately, since they are "included" in the CABG code.
+*On the other hand, things done in OR that are NOT part of the standard procedure (e.g. for someone coming out from OR after CABG who now has ECMO, Swan-Ganz, IABP), you SHOULD code these as [[Admit Procedure]]).
 === 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.
+*When at the same sitting both diagnostic and therapeutic procedures are done, then CODE THEM BOTH
+{{ex|*  a cardiac cath is done and then a stent is placed -- code the diagnostic cath and the therapeutic stenting.
-For endoscopic inspection/explorations, code only the '''"furthest/deepest"''' area assessed.
+* for an [[Angiogram, coronary (diagnostic cardiac catheterization)]] where [[Angioplasty, coronary (with stenting)]] happens in the same sitting, code both}}
+* if a tissue [[Biopsy (non-endoscopic)]]/[[Biopsy (endoscopic)]] is done as part of an invasive [[Inspection, Exploration (non-endoscopic)]]/[[Inspection, Exploration (endoscopic)]] code both
-Examples:
+*When multiple procedures are done at one sitting, code them all
-* for a [[Angiogram, coronary (diagnostic cardiac catheterization)]] where [[Angioplasty, coronary (with stenting)]] happens in the same sitting, only code the [[Angioplasty, coronary (with stenting)]].
+{{Ex|if a CT of chest, abdomen and pelvis is done, code them all}}
-* 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)]].
+*For endoscopic inspection/explorations, code only the '''"furthest/deepest"''' area assessed.
-* If a CT is done on the abdomen, chest and pelvis, enter 3 entries in the component area?
-}}
 === [[Aborted Procedure]] ===
@@ Line 100: / Line 116: @@
 == related literature ==
-[https://secure.cihi.ca/free_products/Coding%20standard_EN_web.pdf CIHI.ca coding standard CCI]
+[https://secure.cihi.ca/free_products/CodingStandards_v2018_EN.pdf CIHI.ca coding standard CCI]