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Data Capture and Coding in Acute Care Surgery: A Case Study from Michigan, Exercises of Health sciences

The data capture process for acute care surgery cases at Michigan, focusing on diseases such as acute appendicitis, cholecystitis, and gallstone pancreatitis. It covers data entry using Qualtrics and MSQC, and provides examples of coding for specific cases, including discontinuity and return to OR. The document also includes instructions for documenting additional information.

What you will learn

  • How is data entered using Qualtrics and MSQC?
  • What additional information should be documented in the case?
  • What is the process for coding return to OR cases?
  • What diseases are covered in the data capture process for acute care surgery cases at Michigan?
  • What are the specific coding instructions for discontinuity cases?

Typology: Exercises

2021/2022

Uploaded on 09/27/2022

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Michigan Acute Care Surgery
Ypsilanti, MI
October 8, 2019
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Download Data Capture and Coding in Acute Care Surgery: A Case Study from Michigan and more Exercises Health sciences in PDF only on Docsity!

Michigan Acute Care Surgery

Ypsilanti, MI

October 8, 2019

Agenda

 Introductions

 Data Capture

 Review of Data

 Qualtrics

 MSQC

 Cases

 Future Meeting(s)

Data Entry

 Qualtrics – all patients meeting criteria

 Acute Appendicitis

 Acute Gallbladder disease

 SBO

 Emergent Exploratory Laparotomy

 Sampled and oversampled

 MSQC

 Operative

Data

 Qualtrics

 Total by hospital

 Diseases

 Operative

 Non-operative

Patients by Disease

Operation

Case A

 SBO with Hernia

 OR

 Dr. A lysis of adhesion's (Colorectal)

 Dr. B hernia repair (Gen Surg)

Case B

 First OR

 Re-exploration of recent laparotomy

 Drainage intraabdominal abscess

 EGD

 Open gastrostomy tube placement

 Second OR

 Re-exploration of recent laparotomy

 Irrigation debridement of abdomen

 EGD

 Placement gastric stent

 Intragastric drain

MSQC – Identify Damage Control Cases

■ Use an unlisted CPT code to flag damage control cases

■ Patients left in discontinuity will have their actual CPT changed to an unlisted CPT

■ Three different CPT codes to choose from based on procedure and area of bowel

■ Appendix C of the MSQC Program Manual

MSQC Codes - Discontinuity

CPT to Enter for Return to OR

■ Qualtrics

  • Enter the actual CPT code (44140) for the first surgery.

■ MSQC

  • First surgery enter CPT 45399 (Colon Left In Discontinuity) from MSQC Table C instead of the actual CPT code and select other procedure(s) that were performed: ■ “Splenic Flexure Mobilization”
  • Second surgery include as return to OR in “Postop Events” section. Use CPT 44320.

Multiple Return to OR

Surgery Performed

■ First Surgery

  • Ischemic bowel 2 days post Vascular Surgery
  • Exploratory laparotomy and resection of 80 cm of terminal ileum, left in discontinuity

■ Second Surgery

  • Exploratory laparotomy with resection of 10cm small bowel, anastomosis of ileum, loop ileostomy

■ Third Surgery

  • Washout and facial closure

Coding ■ First Surgery

  • 44120 – Enterectomy, resect small intestine; single resect and anastomosis

■ Second Surgery

  • 44120 – Enterectomy, resect small intestine; single resect and anastomosis
  • 44310 – Ileostomy/Jejunostomy, nontube ■ Third Surgery
  • 49002 – Reopen recent laparotomy

Documenting Additional Information

■ Comments section at the end of the Qualtrics case

■ Follow-up section in MSQC has a comments section

Case

 Does a sampled MSQC patient require data

entry into Qualtrics?

 Yes, if meets MACS criteria

 Discussion