Performance Measurement Network

Question: Procedures Performed During Hospitalization


This question has follow-up question(s): Procedure codes for HF outpatients

Are lab results considered procedures performed? If the patient is admitted and all he/she has done are labs and no other "procedures" and the lab results are included in our "care transition record" do I say "yes" to "procedures performed"? Also, are you looking for a list of procedures only or must it include the result? For example, if the patient had an echo performed or cardiac cath, do we need to include the results of the procedure in the "care transition record" in order to meet this data element? Thank you.

Answer:

Regarding the procedures performed, lab results would not be included in this data element. Procedures would be diagnostic tests (echo, etc.,) and would have a corresponding ICD-9-CM procedure code accompanying it. If, as you indicate, and echo (which is a procedure that may be completed while the patient is in the hospital) the results may not yet be available at discharge. If the results are available, then it would be nice for the next level of care provider to know, but at this time, the results are not required.

Hope this helps.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: ACHF,
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