ICD-9-CM Principal Procedure Date

Specifications Manual for Joint Commission National Quality Measures (v2015A)

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Release Notes:
Data Element
Version 2015A

Data Element Name:

ICD-9-CM Principal Procedure Date

Collected For:

All Records , Optional for All HBIPS and PBM Records

Definition:

The month, day, and year when the principal procedure was performed.

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

Suggested Data Collection Question:

What was the date the principal procedure was performed?

Format:

Length:	10 MM-DD-YYYY (includes dashes) or UTD
Type:	Date
Occurs:	1

Allowable Values:

MM = Month (01-12)
DD = Day (01-31)
YYYY = Year (20xx)
UTD = Unable to Determine

Notes for Abstraction:

If the principal procedure date is unable to be determined from medical record documentation, select “UTD.”
The medical record must be abstracted as documented (taken at “face value”). When the date documented is obviously in error (not a valid date/format or is outside of the parameters of care [after Discharge Date ]) and no other documentation is found that provides this information, the abstractor should select “UTD.”
Examples:
- Documentation indicates the ICD-9-CM Principal Procedure Date was 02- 42 -20xx. No other documentation in the medical record provides a valid date. Since the ICD-9-CM Principal Procedure Date 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 02-12-20xx and documentation indicates the ICD-9-CM Principal Procedure Date was 03-12-20xx. Other documentation in the medical record supports the date of death as being accurate. Since the ICD-9-CM Principal Procedure Date is after the Discharge Date (death), it is outside of the parameter of care and the abstractor should select “UTD.”
  Note:
  Transmission of a case with an invalid date as described above will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse. Use of “UTD” for ICD-9-CM Principal Procedure Date allows the case to be accepted into the warehouse.

Suggested Data Sources:

Consultation notes
Face sheet
Progress notes
Discharge summary
Diagnostic test reports
Operative notes
Procedure notes
UB-04

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
None	None

ICD-9-CM Principal Procedure Date

Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)