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
Here are the rules for what we will code and what we won't code:
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.
Procedures done on the unit (endoscope or non-therapeutic)
Include all of the following codable procedures done on the unit:
- (a) any procedure that uses an endoscope -- whether inserted through an orifice, incision or wound
- (b) all codable Diagnostic Procedures
- (c) all codable Imaging Procedures
- (d) all codable Obstetric Procedures
- (d) all codable Miscellaneous Procedures
Procedures only coded once per ward stay
In addition to (1) and (2) code the following (and only the following) procedures done in the patient’s unit - but only the FIRST TIME (date) IT WAS DONE during the patient’s stay on that unit
Sublist of these procedures that are chosen from the CCI Picklist:
Sublist of these procedures that are coded as CCI Components:
- PEG -- combine body part (T) Stomach, Pylorus with "what was done" as Bypass
- Debridement -- for which you combine the body part, with the "what was done" CCI code Excision, Resection, partial
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).
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.
- pick the left column, CCI component 1 codes - what organ was something done to.
- 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?
- For those scans (CT/MRI/US/Nuclear med etc) do we choose imaging or diagnostic? Does this depend on the findings? for eg. If the scan is normal is this imaging? and if there is an abnormality is this diagnostic? Lisa Kaita 11:19, 2018 August 22 (CDT)
- Is this about component coding, and which first and second components you can combine? If so: you can actually only code each second component with a first component that matches. I had tried to limit the dropdowns to that but ran into some problems with it, and then never got back to it. Then we changed what we show in the dropdowns and it became that much less intuitive (for this concept, but easier for others...). The deal is, the (T/D/I) at the end of the first component dictates that the second component, when viewed as drop-down, has to have a matching second column. Before we go live I will need to include cross checks for this. I hope to also make it more intuitive by then, even if just by including the (T/D/I) in the name for the second components. Thanks for reminding me about this. Ttenbergen 15:49, 2018 August 22 (CDT)
- AG REPLY -- Yes, imaging modalities shouldn't be available in the "D" category.
Template:CCMDB Data Integrity Checks
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 you still need to enter something so we can test that procedures were not just forgotten. Enter No procedure performed as an Admit procedure into the CCI Picklist, the top of the tab.
Procedures not coded
See List of CCI procedures we don't code
Date Integrity Checks
Must have at least one entry
| Data Integrity Checks | |
| Summary: | every patient ward admission must have at least one CCI Procedure(which might be No procedure performed) |
| Related: | [[CCI_Collection, No procedure performed]] |
| Firmness: | hard check |
| Timing: | complete always |
| App: | CCMDB.mdb |
| Coding: | how to find this in containing program, eg. SAS file, function name, query name... |
| Uses L Problem table: | not relevant for this app |
| Status: | ready to implement |
| Implementation Date: | date change was rolled out / first applied |
| Backlogged: | true |
Will need to be implemented: to click complete:
- must have a other than No procedure performed
- code No procedure performed if there were no procedures
- Px_Date for the Acquired procedures cannot be before Accept DtTm or Arrive DtTm and/or after the Dispo DtTm.
CCI Procedure vs Previous Location Cross Check
| Data Integrity Checks | |
| Summary: | If from OR or PACU, must have at least 1 CCI Procedure |
| Related: | [[CCI Procedure, Previous Location]] |
| Firmness: | hard check (not allowed) or soft check (allowed, but give error; in CFE this means it has to go into the ... table, and cross checks have to consider that table) |
| Timing: | complete always |
| App: | CCMDB.mdb |
| Coding: | how to find this in containing program, eg. SAS file, function name, query name... |
| Uses L Problem table: | not relevant for this app |
| Status: | needs review |
| Implementation Date: | date change was rolled out / first applied |
| Backlogged: | true |
|
|