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

• We code CCI procedures in 5 different CCI Collection Modes:

Collecting "CCI collect each" items

• "CCI collect each" items are entered each time they happen
• Px Date
  • if an Acquired Procedure, enter the Px Date for each day that they happen
  • if an Admit Procedure leave the date blank
• Px Count
  • if they happen more than once on a day, enter the number of times for that day, otherwise enter a Px Count of 1

Collecting "CCI collect count each" items

Blood gas, arterial, and Blood gas, venous are only collected manually at the Grace, at HSC or STB they are automatically uploaded from DSM Lab Extract.

• "CCI collect count each" items are entered as counts of how often they occurred
• Px Date
  • if an Acquired Procedure, enter the Px Date of the first time they happen
  • if an Admit Procedure leave the date blank
• enter the total number of times the procedure was done as Px Count. If it happened as an Admit Procedure and as an Acquired Procedure, enter separately.

Collecting "CCI collect count days" items

• "CCI collect count days" items are entered as counts of how often they occurred
• Px Date
  • if an Acquired Procedure, enter the Px Date of the first time they happen
  • if an Admit Procedure leave the date blank
• enter the total number of days on which the procedure was done, even just for part of the day, Admit Procedure and each Acquired Procedure of this type as Px Count
• this data is cross-checked by query check_CCI_vs_LOS_count_days_component and query check_CCI_vs_LOS_count_days_picklist

Collecting "CCI collect count units" items

• "CCI collect count units" items are entered as counts of how often they occurred
• Px Date
  • if an Acquired Procedure, enter the Px Date of the first time they happen
  • if an Admit Procedure leave the date blank
• enter the total number of units that were administered for each Admit Procedure and each Acquired Procedure of this type as Px Count

Collecting "CCI collect first" items

• "CCI collect first" items are entered the first time they happen
• Px Date
  • if an Acquired Procedure, enter them with the Px Date of the first time they happen
  • if an Admit Procedure leave the date blank and just enter the procedure
• Px Count is always 1 for this collection mode

List of CCI Elements and their collection modes

picklist

Has CCI Collection Mode CCI PickList Procedure CCI collect each

component 2 list

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

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.

Procedure coding for patients that are moved from one ICU/ward to another ICU/ward

• See the "Moved patients" portion of Admit Procedure

Procedures we don't code

We are not tracking all possible procedures. If a procedure can not be coded using the picklist or combined method, then we likely are not interested in coding it.

See List of CCI procedures we don't code for procedures we explicitly don't collect. If you come across a procedure you were not able to code, but think we probably should be coding, please note it there.

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.

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 (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).

• Template:Discussion For clarification, as part of CABG surgeries all patients come with a central line and art line, CT, Pacer but I will not include as they are part of the larger surgery, if they change the lines or insert new CT I will code as acquired. For those that come from the OR with ECMO, Swan Ganz or IABP (not part of a standard CABG procedure), for which we count days, should I enter as admit? and also enter as acquired to count the days? (implies inserted in ICU even though it wasn't) or can I enter multiple days for admit? (this doesn't seem quite correct either) Lisa Kaita 09:39, 2019 January 4 (CST)
• AG REPLY -- as I've now written just above, "Yes" non-standard things done as part of a large procedure should be coded -- IF they meet the usual criterion inclusion. As far as needing to code, e.g. for someone who comes out of OR with ECMO or something else we count days for, as admit AND acquired, I am not aware that there's a necessity to code something as acquired to count days --- TINA???

Related Imaging, Diagnostic and Therapeutic procedures performed at the same time

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

Example:

a cardiac cath is done and then a stent is placed -- code the diagnostic cath and the therapeutic stenting. 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
• When multiple procedures are done at one sitting, code them all

Example:

if a CT of chest, abdomen and pelvis is done, code them all

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

Aborted Procedure

• See Aborted Procedure for how to code

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.

Data Integrity Checks

List of cross-checks

No corresponding old article found

related literature

CIHI.ca coding standard CCI