CCI Collection

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Revision as of 16:22, 2018 June 20 by Ttenbergen (talk | contribs) (→‎Procedures only coded once pre ward stay: removed reference to intubation, chest tube, tracheostomy placement; removed IABP reference from component code since we now have a picklist entry for it.)
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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:

Procedures only coded once pre 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:

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

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" or "acquired"
      2. enter a Px_Date - Date of procedure
      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:

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 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 CCI procedures we don't code



end of instructions, the questions below will eventually be cleared out.


Questions?

  • Do we care that we will not be able to differentiate between a Blakemore tube from an Upper GI scope with banding or hemostasis, when in CCI they both look the same: Therapeutic Intervention on Stomach, pylorus... and Control of Bleeding. --LKolesar 14:11, 2018 May 1 (CDT)
    • discussed at task 14:08, 2018 June 20 (CDT), Julie to review what she needs and we will discuss again Ttenbergen 14:08, 2018 June 20 (CDT)
  • SMW


  • Cargo


  • Categories

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And the content below here will need to stay as well

Date Integrity Checks

Template:CCMDB Data Integrity Checks - Must have at least one entry

Template:Discussion Will need to be implemented: to click complete:

Template:CCMDB Data Integrity Checks - CCI Procedure vs Previous Location Cross Check

If from OR or PACU, must have at least 1 CCI

Related Articles

Related articles:

related literature

CIHI.ca coding standard CCI