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This article provides general information about collecting and coding a [[CCI Procedure]].   
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 ==
== Collection instructions ==
===Start Date: Jan 1, 2019 ===


=== Determining if the procedure you found is one we collect ===
=== Selecting and entering [[CCI]] procedure in [[CCMDB]] ===
*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 '''[[List of CCI procedures we don't code|codable]]''' procedures'' that meet the definition of one of the [[Px Type]]s 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 '''[[List of CCI procedures we don't code|codable]]''' procedures''' done on the unit:
 
=== (C) Other on-unit procedures ===
*(b) all [[List of CCI procedures we don't code|codable]] '''[[Diagnostic Px]]s'''
*(c) all [[List of CCI procedures we don't code|codable]] '''[[Imaging Px]]s'''
*(d) all [[List of CCI procedures we don't code|codable]] '''[[Obstetric Px]]s'''
*(d) all [[List of CCI procedures we don't code|codable]] '''[[Misc Px]]s'''
 
==== [[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:  
Follow these steps, in this order:  
# for every procedure:  
# for every procedure:  
Line 51: Line 15:
##* pick the left column, [[CCI component 1 codes - what organ was something done to]].
##* 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]].
##** 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]].
##* 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,  
## whether CCI picklist or CCI component,  
### enter a [[Px_Type]] - "admit" ([[Admit Procedure]]) or "acquired" ([[Acquired Procedure]])
### enter a [[Px_Type]] - "admit" ([[Admit Procedure]]) or "acquired" ([[Acquired Procedure]])
Line 57: Line 21:
### enter a [[Px_Count]] - the number of '''separate''' times it was done''' '''''on a given day
### enter a [[Px_Count]] - the number of '''separate''' times it was done''' '''''on a given day


=== Repeated procedures ===
==== productivity features ====
If a procedure is done repeatedly '''on the same day''', only enter it once but count it in [[Px_Count]].
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]]s''':
{{:CCI collect each}}
{{:CCI collect count each}}
{{:CCI collect count days}}
{{:CCI collect count units}}
{{:CCI collect first}}
 
=== List of CCI Elements and their collection modes ===
{{Collapsable
| always= picklist
| full=
{{#ask: [[Has CCI Picklist Code::+]][[Has StopDate::>{{CURRENTDAY}} {{CURRENTMONTHNAME}} {{CURRENTYEAR}}]]
|?Has CCI Collection Mode
|format=broadtable
|link=all
|limit=1000
|class=sortable wikitable smwtable
}} }}
{{Collapsable
| always= component 2 list
| full=
{{#ask: [[Has CCI 2 Code::+]][[Has StopDate::>{{CURRENTDAY}} {{CURRENTMONTHNAME}} {{CURRENTYEAR}}]]
|?Has CCI Collection Mode
|format=broadtable
|link=all
|limit=1000
|class=sortable wikitable smwtable
}} }}


Procedures done on a '''different''' day should be entered again with a different date. This should be really quick by using the "duplicate" button.
== Special Cases ==
=== 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.


=== Related Imaging, Diagnostic and Therapeutic procedures performed at the same time ===
=== Moved patients ===
Some intervention are both diagnostic/imaging and therapeutic. For those situations, only code the therapeutic part.
*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.


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


Examples:
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 [[List of CCI procedures we don't code|there]].
* for a [[Angiogram, coronary (diagnostic cardiac catheterization)]] where [[Angioplasty, coronary (with stenting)]] happens in the same sitting, only code the [[Angioplasty, coronary (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 ===
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.
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.


{{Discuss | who = Allan | question =  
=== Don't code sub-procedures that are part of a larger procedure ===
*How do we put the procedure: thrombectomy of the femoral artery for a blocked vascular graft (axillo-femoral graft). Please advise. --[[User:LKolesar|LKolesar]] 13:14, 2018 December 11
*Do not code a procedure that is part of a "Bigger" procedure already coded.  
*AG REPLY --- in general it appears that procedures performed on vascular grafts (either synthetic grafts or vessels harvested from elsewhere for use) are coded just as you would if the same thing was done to the native vessel. So this would be 1.KG.57 = therapeutic EXTACTION procedure [which includes thrombectomy] on arteries of the leg NOS [which includes the femoral arteries] }}
'''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]]).


=== No Procedures Performed ===
=== Related Imaging, Diagnostic and Therapeutic procedures performed at the same time ===
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.
*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 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
{{Ex|if a CT of chest, abdomen and pelvis is done, code them all}}
*For endoscopic inspection/explorations, code only the '''"furthest/deepest"''' area assessed.


=== Procedures not coded ===
=== [[Aborted Procedure]] ===
See [[List of CCI procedures we don't code]]
*See [[Aborted Procedure]] for how to code


== Proposed tweak ==
=== Repeated procedures ===
As discussed [[Task_Team_Meeting_-_Rolling_Agenda_and_Minutes#ICU_Database_Task_Group_Meeting_.E2.80.93_October_31.2C_2018]]:
If a procedure is done repeatedly '''on the same day''', only enter it once but count it in [[Px_Count]].  
*After discussion we '''recognized that we will need to create machinery to code 3 different categories of such procedures''':
**(i) Those coded every time they occur -- recorded with dates.  Example is EGD
**(ii) Those for which we mainly want total counts -- record the first date in which done, plus the total count over the entire admission.  Example is CXR, ABG.  For this one there is needed software/data entry “machinery” that Tina/Trish/etc will talk about offline.
**(iii) Those for which we would ‘’prefer’’ the # of days on which it was done.  Examples are noninvasive mechanical ventilation, dialysis, ECMO.  However, after discussion we decided that in order to reduce the workload on the data collectors, we will only collect the date of the first use.  We could reconsider adding # of days for these at a later point in time.


{{Discuss | who = All | question =
Procedures done on a '''different''' day should be entered again with a different date. This should be really quick by using the "duplicate" button.
* Thoughts? }}


==Data Integrity Checks ==
==Data Integrity Checks ==
{{#ask: [[DICSummary::+]] [[Category: CCI Px check]]
{{Collapsable
| always= List of cross-checks
| full= {{#ask: [[DICSummary::+]] [[Category: CCI Px check]]
|?DICSummary = summary
|?DICSummary = summary
|?DICStatus = implementation status
|?DICStatus = implementation status
Line 104: Line 110:
|limit=100
|limit=100
|link=all
|link=all
|headers=show}}
|headers=show}} }}


== Related Articles ==
== Related Articles ==
Line 110: Line 116:


== related literature ==
== 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]





Latest revision as of 15:56, 2023 October 31

This article provides general information about collecting and coding a CCI Procedure.

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

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:

  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.
    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

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

Collecting "CCI collect each" items

Collecting "CCI collect count each" items

Blood gas, arterial, and Blood gas, venous are not manually counted at HSC or STB sites, as it is automatically uploaded from DSM Lab Extract.

Collecting "CCI collect count days" items

Collecting "CCI collect count units" items

Collecting "CCI collect first" items

List of CCI Elements and their collection modes

picklist   
 Has CCI Collection Mode
AXR (abdominal plain X-ray)CCI collect count each
Amniocentesis (non-imaging diagnostic)CCI collect first
Angiogram, aortic (any part of aorta)CCI collect each
Angiogram, artery NOS (except specifically coded)CCI collect each
Angiogram, cerebral (including vertebral arteries)CCI collect each
Angiogram, coronary (diagnostic cardiac catheterization)CCI collect each
Angiogram, pulmonary artery (pulmonary arteriogram)CCI collect each
Angiogram, veinCCI collect each
Angioplasty, coronary (with stenting)CCI collect each
Angioplasty, coronary (without stenting)CCI collect each
Arterial catheterization, any locationCCI collect first
Arthrocentesis, diagnosticCCI collect first
BMT (Bone marrow transplant or transfusion)CCI collect first
BiPAP, CPAP, NIV, own ventilator (Mechanical ventilation, noninvasive)CCI collect first
Blank procedure entryCCI collect each
Blood gas, arterialCCI collect count each
Blood gas, venousCCI collect count each
CAM positive (TISS Item)CCI collect each day
CAR-T (Chimeric Antigen Receptor T-cell Immunotherapy)CCI collect each
CCI PickList ProcedureCCI collect each
CPR within past 24 hrs (TISS Item)CCI collect each day
CPR, cardiac resuscitationCCI collect first
CRRT (TISS Item)CCI collect each day
CRRT (incl volume removal via PRISMA device)CCI collect first
CT of chest with PE protocol (CT angiogram of pulmonary vessels)CCI collect each
CVC placement, any locationCCI collect first
CXR (plain film)CCI collect count each
Capsule EndoscopyCCI collect each
Cardiac CT or Cardiac CT angiogram (with or without coronary arteries)CCI collect each
Cardiac MRICCI collect each
Cardiac electrophysiology studyCCI collect first
Cardiac nuclear scan (e.g. MUGA)CCI collect each
Cardiac stress test (any kind)CCI collect each
Cardioversion (EXCLUDE defibrillation-we are not tracking)CCI collect first
Central venous catheter (TISS Item)CCI collect each day
Cesarean section delivery (therapeutic)CCI collect first
Chest tube, left in placeCCI collect first
Defibrillator, insertionCCI collect first
ECHO (echocardiogram of heart)CCI collect each
ECMO, VACCI collect count days
ECMO, VVCCI collect count days
ECT (Electroconvulsive shock therapy to brain)CCI collect first
EEG (electroencephalography)CCI collect first
ERCP (endoscopic retrograde cholangiopancreatography)CCI collect each
ETT Present (TISS Item)CCI collect each day
HD (Hemodialysis)CCI collect first
IABPCCI collect first
ICP monitor (Placement of implanted, invasive intracranial pressure monitoring device)CCI collect first
IV hyperalimentation (TISS Item)CCI collect each day
IVIG (IV administration of immunoglobulin)CCI collect first
Induction of labor (therapeutic)CCI collect first
Insertion of ETT (TISS Item)CCI collect each day
Intermittent hemodialysis (TISS Item)CCI collect each day
Intracranial pressure monitoring (TISS Item)CCI collect each day
Invasive Mechanical Ventilation (TISS Item)CCI collect each day
Isolation, infectiousCCI collect first
LP (lumbar puncture, diagnostic)CCI collect first
Nephrostomy placementCCI collect first
No TISS Item (TISS Item)CCI collect each day
No codable procedure done in ORCCI collect first
No procedure enteredCCI collect first
No procedure performedCCI collect first
Non-invasive CPAP or BIPAP (TISS Item)CCI collect each day
PD (Peritoneal dialysis)CCI collect first
PFT (pulmonary function test)CCI collect first
Pacemaker insertion, permanentCCI collect first
Pacemaker insertion, temporaryCCI collect first
Paracentesis (diagnostic)CCI collect first
Patient is on isolation (TISS Item)CCI collect each day
Peripheral arterial line (TISS Item)CCI collect each day
Peritoneal dialysis (TISS Item)CCI collect each day
Planned extubation (TISS Item)CCI collect each day
PlasmapheresisCCI collect first
Postpartum surgical repair (therapeutic) -- incl episiotomyCCI collect first
Prone positioningCCI collect each day
Pulmonary arterial line (TISS Item)CCI collect each day
Right heart catheterization, in cardiac cath labCCI collect each
SVD (Spontaneous vaginal delivery)CCI collect first
Sleep Study (Polysomnogram, done in Miseracordia Sleep lab)CCI collect first
Supp O2 through any device, delivered via nose, mouth, ETT or trach (TISS Item)CCI collect each day
Suppression of labor (therapeutic) - incl via pharmacologic tocolyticsCCI collect first
Surgical removal of extrauterine pregnancy (therapeutic)CCI collect first
Suturing of cervical os (therapeutic)CCI collect first
Swan-Ganz (Pulmonary Artery Flotation) Catheter placementCCI collect first
TIPS (transjugular intrahepatic portosystemic shunt)CCI collect each
TPN (Total parenteral nutrition)CCI collect first
Targeted Temperature Management (TTM)CCI collect first
Termination of pregnancy pharmacologic (therapeutic)CCI collect first
Termination of pregnancy surgical (therapeutic)CCI collect first
Thoracentesis (diagnostic)CCI collect first
Trach Tube Present (TISS Item)CCI collect each day
Tracheostomy creationCCI collect first
Transfusion of PRBCCCI collect count units
Transfusion of albuminCCI collect first
Transfusion of plasma productsCCI collect count units
Transfusion of plateletsCCI collect count units
Unplanned extubation (TISS Item)CCI collect each day
Urodynamics study (cystometrogram, done by urology lab)CCI collect first
Vasoactive drug IV continuous-multiple simultaneous (TISS Item)CCI collect each day
Vasoactive drug IV continuous-single (TISS Item)CCI collect each day
component 2 list   
 Has CCI Collection Mode
(T) NOSCCI collect each
AmputationCCI collect each
Biopsy (endoscopic)CCI collect each
Biopsy (non-endoscopic)CCI collect each
BypassCCI collect each
Closure of fistulaCCI collect each
Computerized Tomography (CT)CCI collect each
Construction, ReconstructionCCI collect each
Control of BleedingCCI collect each
DebridementCCI collect first
DestructionCCI collect each
DilationCCI collect each
Drainage, EvacuationCCI collect each
Excision with Reconstruction, ReplacementCCI collect each
Excision, ResectionCCI collect each
ExtractionCCI collect each
FixationCCI collect each
FusionCCI collect each
Implantation of Internal DeviceCCI collect each
Inspection, Exploration (endoscopic)CCI collect each
Inspection, Exploration (non-endoscopic)CCI collect each
MRICCI collect each
Nuclear ImagingCCI collect each
OcclusionCCI collect each
Pharmacotherapy, thrombolytic agentCCI collect each
Procure, Harvest, Obtain for Further UseCCI collect each
Radiation TherapyCCI collect first
ReattachmentCCI collect each
Release, DecompressionCCI collect each
Removal of Foreign BodyCCI collect each
RepairCCI collect each
TransplantCCI collect each
UltrasoundCCI collect each

Special Cases

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

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 Procedure).

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:   
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

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   
 summaryimplementation status
Query check CCI TISS CAM positive vs DxChecks that each T9 - CAM positive (TISS Item) goes with an ICD10 code from Category:Deliriumdeclined
Query NDC Dialysis TISS CCICritical care patients who have CCI entries for a type of dialysis must have a TISS28 entry for the same type of dialysis as well, and vice versa.declined
Check CRF vs ARF across multiple encountersIf a patient had a comorbid of CRF in any previous admission then ARF can not be an admit or complication in subsequent admissions.declined
Query check CCI TISS time means must be twoIf certain Px Dates have a time component, then there should also be a matching CCI Picklist without the timedeclined
Query check TISS each dayThere needs to be at least one TISS entry in CCI Picklist for each day for each ICU profile.declined
Query check CCI component 1 and 2 compatibleComponent CCIs must have compatible component 1 and component 2implemented
Query check CCI vs LOS count days picklistConfirm that CCI Collection Mode for CCI Picklist CCI collect count days items don't have a count > LOS.implemented
Query check CCI vs LOS count days componentConfirm that CCI Collection Mode or CCI Component CCI collect count days items don't have a count > LOS.implemented
Query check CCI TISS if no then noneIf No TISS Item (TISS Item) in CCI Picklist there must be no other entry from TISS Item List in CCI Picklist, and vice versaimplemented
Query check CCI if no then noneIf No procedure performed in CCI Picklist there must be no other entries in CCI Picklist or CCI Componentimplemented
Query check CCI from OR no CCIIf from OR or PACU, must have at least 1 CCI Procedure other than No procedure performedimplemented
Query check CCI TISS matching BoardingLoc timeIf the Px Date component of a CCI Picklist has a time, then there must be a corresponding Boarding Loc entryimplemented
Query check ICD10 trach has trach but no TISSIf there is a Tracheostomy, has one (Z93.0) ICD10, there should likely be a T23 - Trach Tube Present (TISS Item)implemented
Query check ICD10 trach create but no TISSIf there is an acquired Tracheostomy creation there also has to be a Trach Tube Present (TISS Item)implemented
Query check CCI Component duplicatesNo duplication of CCI Component Px_Type, Px_Dateimplemented
Query check CCI Picklist duplicatesNo duplication of CCI Picklist Px_Type, Px_Date, Px_Countimplemented
Sub Dx CheckerRuns most Category:Old_dx_check, Category:ICD10 Dx check, Category:CCI Px check, and a few other checks for dxsimplemented
Query check CCI TISS NrDays GT LOSThere are more TISS Item Px_Dates than there are days between the first Service tmp entry and Dispo DtTmimplemented
Query check CCI TISS NrDays LT LOSThere are more TISS Item Px_Dates than there are days between the first Service tmp entry and Dispo DtTmimplemented
Query check CCI must have entryThere must be at least 1 CCI entry in L_CCI_Picklist table (which might be No procedure performed)implemented
Query check CCI Component no admin entriesThere must be no No procedure entered/Blank procedure entry in CCI Component.implemented
Query check CCI Picklist if no admin entriesThere must be no No procedure entered/Blank procedure entry in CCI Picklist.implemented
Query check ICD10 trach dxs consistentTracheostomy related CCI and ICD10 codes must be consistent with each other.implemented
Query check CCI Component unfilledCCI Component entry with missing px, Px_Type or Px_Countimplemented
Query check CCI Picklist unfilledCCI Picklist entry with missing px, Px_Type or Px_Countimplemented
Query check CCI DatePx Date must be sensible when compared to first Service tmp entry and Dispo_DtTmimplemented
Query check eliminated CCI Compdisallows any currently entered diagnosis that has been eliminatedimplemented
Query check eliminated ICD10disallows any currently entered diagnosis that has been eliminatedimplemented
Query check eliminated CCI Pickdisallows any currently entered diagnosis that has been eliminatedimplemented
Query check CCI CXR vs LOSConfirm that a Category:Labs Imaging count is not unreasonably highneeds review
Query check CCI CRRT vs TmpIf CCI CRRT (incl volume removal via PRISMA device) exists there should be a tmp CRRT entry and vice versaretired
Query NDC TISS CCI endoscopicIf pt has T26 & 27 - Endoscopy (TISS Item) then there must be an endoscopic CCI for that day.retired
Query NDC cardioversion dx vs TISSIf pt has Acquired Procedure Cardioversion (EXCLUDE defibrillation-we are not tracking), then the TISS28 item T26 & 27 - Cardioversion (TISS Item) (T41) must be marked.retired
Query NDC zCRRT CCI Px but no TISSIf there is a T33 - CRRT (TISS Item) then there should be a CRRT (incl volume removal via PRISMA device) CCI Pxretired
Query NDC zCRRT TISS but no CCI PxIf there is a T33 - CRRT (TISS Item) then there should be a CRRT (incl volume removal via PRISMA device) CCI Pxretired
Query NDC Trach Dx TISSTracheostomy ICD10s and CCIs must be consistent with Trach TISS.retired

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