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

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