Performance Measurement Network

Numerous questions have been posted expressing concerns regarding data abstraction for the April 2010 Specifications Manual. Please see the information provided below in response to these issues.

Answer:

The Centers for Medicare & Medicaid Services (CMS) has made the determination that at this time there will be NO changes or an addendum to the current Hospital Inpatient Specifications Manual (effective for April 2010 discharges).

In light of this, we are providing guidance on how to abstract five specific data elements:

SURGICAL INCISION TIME concerning the ‘laparoscopic to open’ exception: If the surgery starts as a laparoscopic procedure which then converts to an open procedure, abstract the Surgical Incision Time for the open procedure. If there is no documentation of when it converted to an open procedure, follow the instructions using the Inclusion List of terms for this data element in the Specifications Manual. If you have two or more terms that represent an incision time, use the earliest time documented.

URINARY CATHETER: Beginning with discharges starting April 2010, if there is no documentation that the patient had a urinary catheter during the hospitalization, select Value 2.

INFECTION PRIOR TO ANESTHESIA concerning joint revisions and cultures: To select ‘Yes’ to Infection Prior to Anesthesia, documentation must show a) the current principal procedure is a joint revision, AND b) a culture of the operative wound was taken prior to the administration of the prophylactic antibiotic. To be considered a joint revision for this exception, the same joint as the principal procedure must have been operated on in a previous surgery that was a total or partial arthroplasty OR there must be documentation that hardware was removed during the current principal procedure.

ANESTHESIA TYPE: To select Value 2 or Value 3 there must be documentation that the procedure was performed using epidural anesthesia. This data element does not address epidurals that are used for pain control so the medical record must be abstracted according to the instructions in the current manual.

REASONS TO EXTEND ANTIBIOTICS concerning joint revisions, cultures and current malignancies: Select Value 5 only if there is physician documentation within 2 days after a joint revision that the patient has a current malignancy of the same lower extremity listed as the principal procedure in the joint revision surgery.

To select Value 6, documentation must show a) the current principal procedure is a joint revision, AND b) a culture of the operative wound was taken prior to the administration of the prophylactic antibiotic.

We hope these instructions will answer questions surrounding these data elements. Your feedback is appreciated and we strive to remain responsive to your concerns.

If you have additional questions or comments about these data elements, please send them to QUEST: https://www.qualitynet.org/dcs/ContentServerpagename=Quest/Content/Search

Or to The Joint Commission: http://manual.jointcommission.org

Thank you.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: SCIP, Surgical Incision Time, Urinary catheter, Infection Prior to Anesthesia, Anesthesia type, Reasons to extend antibiotics
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