FAQ's

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I have a “neck injury NFS” as a diagnosis (I don’t have any other dx). This is coding out to an S19 code which is not an...

When a patient is transferred out and we receive a follow up letter (usually a discharge summary is attached), do we update...

I understand how to capture Covid testing results for patients who present as Covid positive at time of admission. I enter...

Would you consider an infiltrate from a peripheral IV an iatrogenic injury?

I have a question when abstracting information from an OSH. I have a patient who was seen after falling off the bed of his...

We have an inclusion question on a patient. Patient came in as a Level 1 alert Patient was found on the floor next to bed...

There is a situation where a person was on site at out hospital being seen in a clinic ( clearly not an admitted patient)...

Can you clarify the “injury type” when coding a severe friction abrasion burn that occurs in situations such a motorcycle...

We have been having a bit more holding in our ER than normal because of COVID patients. We recently had a patient...

The State Trooper stops a vehicle. The vehicle begins to drive away. The State Trooper dives into the car window. He is...

Hypothermia, if a patient has a temp of 35.7 C can we code this as hypothermia or is the cut off 35 C?

I’m looking for some coding help. I have a CT scan report stating complex maxillofacial, Lefort type fractures, no specified...

We have a patient that had a fall on 11/14/2020, trauma saw him, scans negative and he was discharged home from ED...

Do all hospital events/occurrences need physician documentation in the chart for us to count the event? (This was based on...

In PTOS manual for Patient monitoring during Radiology Studies, does this question apply to all patients or just trauma...

We have a patient that sustained a GSW to the Abd that resulted in a grade 5 liver lac. For AIS purposes would we grade both...

If the patient had multiple repairs of several different lacerations of the face is it correct that we don’t have to code...

Patient is only in the ER for 15 minutes, and they did not have a complete set of vitals documented, how do I answer this field?

We have a patient that was injured 11/1/20 @ 126am and entered the Hospital ED is 11/1/20 @ 1am. The time of death as we have...

We have a patient that has “early cellulitis at abrasion site pinky, recommend Keflex 500 b.i.d. x 5 days”. Would this be...

If the patient had >100,000 Presumptive Actinomyces Species in urine – on Rocephin, collected in the time frame to meet UTI...

I have a patient discharged to Marywood Heights. When I went on their website they are a retirement community offering...

During the conference we noticed in your presentations that you answered unknown to GCS qualifiers when you had unknown...

I have a patient on admission diagnosis with ESRD-Stage V, recently had fistula placed with intentions of starting dialysis...

Where is the Support tab on the Portal located?

Do we enter the dates in the ICU/Vent tabs of Collector if the total hour was less than 2-3 hrs?

Do we pick up extubation less than 24hrs code in procedures?

If a patient meets criteria for both UTI and CAUTI, do you enter both events? or one versus the other?

On NPTOS charts that do not meet inclusion criteria for PTSF, NTDB/TQIP inclusion criteria, we should click on “Exclude from...

What is the PTSF Web Portal?

We have a patient who was transferred to our facility via ambulance from one of our sister hospitals for a wrist and finger...

So I have a pt that was physically assaulted by her nephew (who was living with her) for a couple of hours. Punched in the...

I have a patient who received an electrical shock from touching a piece of machinery that was touching a 220 volt power...

I have a patient that tested positive for Covid and was given Convalescent Plasma for Covid. I wasn’t sure if I should enter...

I have a patient that sustained and injury while he was in the ED waiting to be discharged. The injury he sustained then...

Do you know what IT needs we need to make sure we have in place in order for a virtual educational “visit”? We are currently...

Do you know what IT needs we need to make sure we have in place in order for a virtual educational “visit”? We are currently...

Can you tell me what the “P” when referred to in triss means?

I have a case where a patient had a fall down steps resulting in a SDH. The patient was taken emergently for a crani/...

How am I to code COVID Test Results for the NTDB? I'm confused regarding suspected COVID.

I need your valued opinion on a tourniquet code. I’m aware tourneys are coded if it’s the only procedure to control bleeding...

I have a question about one of the charts I am working on. This patient came to us in the evening however the scribe nurse at...

I’ve come across a problem when coding nasal bone fxs. The patient has closed bilateral displaced and comminuted fxs...

Due to our unusually longer ED dwell times, sometimes patients are stable and then deteriorate suddenly hours after arrival...

When a patient arrives via walk in or private vehicle, are we to capture private vehicles and walk ins as mode of arrival?...

I have a question regarding ambulance records. If a patient only had one ambulance for scene and transport and the only set...

I find myself questioning these fields whenever the GCS is nto documented within the 1st 30 min of pt arrival to our...

Could you please send me the instructions for COVID rules for PTSF and TQIP?

I just came across a procedure I have never heard of and certainly never coded …. a lung pacer... I have researched the...

What do you think would be the best mechanism code to use for this scenario? Pt taped .44 ammo to a BB gun and shot himself...

I have a question about Cardiac Arrest with CPR. This pt. arrested upon landing on our roof helipad and arrived to the trauma...

There is a Pilot project through EMS in our area that is having EMS start IV abx for open fx patients in the field. For the...

I have a patient that was seen at one of our sister hospitals for an open fx and then transferred to us, but the patient came...

I have a nursing home patient who presented with + COVID test results documented at their facility from a week prior...

If a patient is ascending a staircase and he trips and falls forward, how would height be determined?

Unplanned Intubation: If the MD intubates a patient as he feels that early intubation is the best course of action does that...

I have a nursing home patient who presented with + COVID test results documented at their facility from a week prior...

I am having difficulty assisting the new registrar with a procedure code for CT angio of the upper extremity to look for...

I was hoping I could receive some help from you, we need assistance with the linkage number. We couldn't determine what that...

If someone is on methadone for substance abuse, has been clean for 2 years I would put yes for prescribed medication...

Ok we are trying to get a better understanding of the inclusion vs exclusion criteria for the PTOS patients. On page 14...

We had a patient that came in with known pleural effusions present on admit. We admitted for spinal fxs. Over the course of...

If I have an Amish patient who was helping a group of other Amish men to repair a neighbors barn when he got hurt would you...

We have a question about the abuse field. Are we to answer this yes or no by the screening done on everyone or is this only...

Hoping you can help with this scenario? . I have a patient that arrived by EMS and has the ED Arrival Time as 0044....

Can you please clarify how to correctly code an acute on chronic head injury? For example, radiology report states “Mixed...

For the pre-existing condition CAD, would documentation of “coronary atherosclerosis” and/or “atherosclerotic vessel disease”...

How am I to code abuse for the NTDB?

How do I assign a facility ID in my editable drop down menu? What happens once this number is added in Collector to the main...

Could you please clarify : If a patient is in the ICU (5/22) and d/c from the ICU on 5/24 However, goes to OR 5/23 Do you...

I have a patient who was the driver of a pickup truck that slid on ice and hit a pole, patient attempted to driver home, his...

If a patient is awake and alert talking to the BLS ambulance crew at the scene but they do not have a GCS documented, I know...

I have a quick question regarding an ICD 10 procedure. Would a right hip hemiarthroplasty be given the code for "replacement...

Our registry had a question that came up during a discussion about highest level of care provided on scene. The definition...

A patient arrives in arrest and remains in arrest and dies in the ED. There is not a note that is clearly documented as GCS...

I have the following validation error: ICU + Step Down Days cannot be greater than total hospital days. Patient was...

What is the best ICD10 code for EVD placement. 00H632Z OR 0096030Z? The guidelines suggest 00_6, but both of these codes...

Scenario: Patient loses control while riding a dirt bike. Was wearing a helmet (but improperly). Helmet comes off during...

I want to make certain I am coding this correctly. I know effacement equals compression as listed in a previous FAQ...

Do you consider a nasal bone fracture (251002) an open or closed fracture?

I have a question about a tension pneumothorax. My patient came into our facility with bilateral pneumothoraxes on 2/24/20...

If we have a patient that fell because they “stepped on soap” causing them to slip and they had only an isolated hip fx...

I’m writing the guidelines for our registrars to include covid or suspected covid within the injury narrative. My question is...

When I login to the PSTF education hub to view courses-the only courses available are a Basic Registrars course and an...

If a patient comes into the Trauma Center and the ED Discharge Destination is the Operating Room, could this be counted as...

In regards to the Hospital Event Delirium, does Catatonic count? I feel like so many patients can have this as an event...

Our PI is questioning the reasoning for a patient that was put No for the question Is there hourly documentation beginning...

I have a question related to the Hospital Event #212 Unplanned Visit to the Operating Room. We had an unplanned operative...

We had a chart where the Resource Coordinator from the Behavioral Heath team spoke with patient and family. How would we...

I recently contacted AAAM in regards to criteria for a question on LeFort fx's and if having the specific facial fx's listed...

I have a question regarding a patient that was an MCC with a partial amputation with multiple open fractures. Our PI nurse is...

Am I remembering correctly that we are to start collecting on cases with an admission date of April 1, 2020? Is that for both...

Mechanism of Injury in cases of abuse

When should we be picking up MTP?

Question regarding Organ Donation

If we have a patient that is going home (SBF) but on Hospice. How do we answer Discharge Destination?

Do we need to answer question on additional NTDB elements re: transfer to NTDS?

I have an OR note that states that a tourniquet “applied” but not inflated at all during OR”. Do I pick it up?

I am trying to code a burn of 9.5% but it is rounding up and applying an incorrect code for 10% + burn?

Can I ask for a quick clarification on the Unplanned Visit to the OR?