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.

• If the principal procedure date is unable to be determined from medical record documentation, leave blank.
• 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 leave blank.
  Examples:
  • Documentation indicates the ICD-9-CM Principal Procedure Date was 02- 42 -2008. 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 leave blank.
  • Patient expires on 02-12-2008 and documentation indicates the ICD-9-CM Principal Procedure Date was 03-12-2008. 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 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
• Diagnostic test reports
• Operative notes
• Procedure notes
• UB-04, Field Location: 74