Note: If transmitted for the HBIPS measure set, all applicable edits (e.g., valid value, ICD-9-CM Other Procedure Codes exists, etc.) will apply.

• If the procedure date for the associated procedure is unable to be determined from medical record documentation, enter UTD.
• The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid format/range or outside of the parameters of care [after Discharge Date ]) and no other documentation is found that provides this information, the abstractor should leave blank.
  Examples:
  • Documentation indicates the ICD-9-CM Other Procedure Dates was 02- 42 -2008. No other documentation in the medical record provides a valid date. Since the ICD-9-CM Other Procedure Dates is outside of the range listed in the Allowable Values for “Day,” it is not a valid date and the abstractor should select “UTD.”
  • Patient expires on 02-12-2008 and documentation indicates the ICD-9-CM Other Procedure Dates was 03-12-2008. Other documentation in the medical record supports the date of death as being accurate. Since the ICD-9-CM Other Procedure Dates is after the Discharge Date (death), it is outside of the parameters of care and the abstractor should leave blank.
    Note:
    Transmission of a case with an invalid date as described above will be rejected from the Joint Commission’s Data Warehouse.

• Consultation notes
• Face sheet
• Progress notes
• Discharge summary
• Operative report
• Procedure notes
• Diagnostic test reports
• UB-04, Field Locations: 74A-E