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 codable procedures that meet the definition of one of the Px Types 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 codable procedures done on the unit:

(C) Other on-unit procedures

• (b) all codable Diagnostic Procedures
• (c) all codable Imaging Procedures
• (d) all codable Obstetric Procedures
• (d) all codable Miscellaneous Procedures

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:

1. for every procedure:
   1. 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.
   2. 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.
   3. whether CCI picklist or CCI component,
      1. enter a Px_Type - "admit" (Admit Procedure) or "acquired" (Acquired Procedure)
      2. enter a Px_Date - Date of procedure for acquired px only
      3. 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. Check fundamentals for CCI uses this to make sure that entering procedures was not just forgotten.

Px Count with No procedure performed

Should we have Px Count restrictions when using No procedure performed? Having a requirement to make count = 0 would make even more certain that it was entered intentionally. Yet, requiring other than default entry would add marginally more work for collectors, and getting one more error might mean other errors are not read as thoroughly. Looking for input... Ttenbergen 15:21, 2018 September 27 (CDT)

• SMW

• Cargo

• Categories

Procedures not coded

See List of CCI procedures we don't code

Data Integrity Checks

• Check CRF vs ARF across multiple encounters
• Check Isolation Px vs Isolation Dx
• Eliminating a diagnosis from collection
• Query NDC Dialysis TISS CCI
• Query NDC TISS CCI endoscopic
• Query NDC Trach Dx TISS
• Query NDC cardioversion dx vs TISS
• Query NDC zCRRT CCI Px but no TISS
• Query NDC zCRRT TISS but no CCI Px
• Query check CCI CRRT vs Tmp

... further results

related literature

CIHI.ca coding standard CCI