Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

Data Element Name: ICD-10-PCS Principal Procedure Time
Collected For: CSTK-01, CSTK-03
Definition:The time (military time) when the principal procedure was performed.
Suggested Data Collection Question:What was the time that the principal procedure was performed?
Format:
Length:5 - HH-MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:


HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Examples:

Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the ICD-10-PCS Principal Procedure Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting Midnight or 24:00 to 00:00, do not forget to change the ICD-10-PCS Principal Procedure Date.
Example:
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00.
  • The ICD-10-PCS Principal Procedure Time is the time associated with the start of the principle procedure performed during the hospitalization. If a patient enters the operating room or interventional suite, but the principal procedure is canceled before it is initiated and the principal procedure performed at a later time, the ICD-10-PCS Principal Procedure Time is the start time when the procedure was actually performed.
  • For bedside procedures, e.g. external ventricular drain (EVD) placement, the time documented on the bedside flowsheet/nurses note should be used if earlier than other times documented on a procedure record or in other sources.
  • If the start time when the principal procedure was performed 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 principal procedure start time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Example:
    Documentation indicates the start time of the ICD-10-PCS Principal Procedure was 3300. No other documentation in the medical record provides a valid time. Since the start time of the ICD-10-PCS Principal Procedure is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD".
    Note:Transmission of a case with an invalid time as described above will be rejected from the Joint Commission’s Data Warehouse. Use of “UTD” for ICD-10-PCS Principal Procedure Time allows the case to be accepted into the warehouse.
  • If the principal procedure start time is obviously incorrect (in error) but it is a valid time and the correct time can be supported with other documentation in the medical record, the correct time may be entered. If supporting documentation of the correct time cannot be found, the medical record must be taken at face value.
    Examples:
    • The principal procedure start time is documented as 10:00 but other documentation in the medical record supports the correct time as 22:00. Enter the correct time of 22:00 as the ICD-10-PCS Principal Procedure Time.
    • The principal procedure end time of 11:58 is documented but the principal procedure start time is documented as 11:57. If no other documentation can be found to support another principal procedure start time, then it must be abstracted as 11:57 because the time is not considered invalid or outside the parameter of care.
Suggested Data Sources:

  • Anesthesia record
  • Consultation notes
  • Face sheet
  • Nursing notes
  • Nursing flow sheet
  • Progress notes
  • Diagnostic test reports
  • Operating room notes
  • Operative report
  • Procedure notes
  • ICU notes
  • Administrative record
  • Bedside flowsheet
  • Circulator record
  • Intraoperative record
  • Procedure record
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion

1. Locate an inclusion term in a suggested data source in no particular order. Use the earliest time associated with an inclusion term that represents the ICD-10-PCS Other Procedure Time(s).

2. If no inclusion terms are found on any suggested data source, look for alternative terms associated with the procedure start time. If none are found, other sources can be used in no particular order. Use the earliest time that represents the ICD-10-PCS Other Procedure Time(s).
  • Procedure start
  • Procedure begin
  • Procedure initiated

None

ICD-10-PCS Principal Procedure Time
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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