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. 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.

Procedures not coded

See List of CCI procedures we don't code

Data Integrity Checks

	summary	implementation status
Query check CCI TISS CAM positive vs Dx
Query NDC Dialysis TISS CCI
Query check CCI TISS time means must be two
Query check TISS each day
Query check CCI component 1 and 2 compatible
Query check CCI vs LOS count days picklist
Query check CCI vs LOS count days component
Query check CCI TISS if no then none
Query check CCI if no then none
Query check CCI from OR no CCI
Query check CCI TISS matching BoardingLoc time
Query check ICD10 trach has trach but no TISS
Query check ICD10 trach create but no TISS
Query check CCI Component duplicates
Query check CCI Picklist duplicates
Sub Dx Checker
Query check CCI TISS NrDays GT LOS
Query check CCI TISS NrDays LT LOS
Query check CCI must have entry
Query check CCI Component no admin entries
Query check CCI Picklist if no admin entries
Query check ICD10 trach dxs consistent
Query check CCI Component unfilled
Query check CCI Picklist unfilled
Query check CCI Date
Query check eliminated CCI Comp
Query check eliminated ICD10
Query check eliminated CCI Pick
Query check CCI each count vs LOS
Query check CCI CRRT vs Tmp
Query NDC TISS CCI endoscopic
Query NDC cardioversion dx vs TISS
Query NDC zCRRT CCI Px but no TISS
Query NDC zCRRT TISS but no CCI Px
Query NDC Trach Dx TISS

related literature

CIHI.ca coding standard CCI