FAQ's

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Is there a list of definitions of what makes a interstate highway, i.e. number lanes, divided?

We had a patient come through the ED, got admitted for a pelvic fx, and expired 22 hours of being here (this time starts at...

We recently had a patient who went to a sister hospital ED and got transferred to us as a direct admission, and then got...

Could you please guide me to the correct code for "subfalcine herniation of the cingulate gyrus?"

I am clarifying AKI hospital event to someone and wanted to make sure I am delivering the clarification correctly...

What is the code for a patient that is pushed intentionally from a moving vehicle?

We have been capturing the trauma surgeons and APs on this screen regardless of whether the called time and/or note time fall...

We noticed that the spinal cord injury pre-existing condition lists all parts of the spine EXCEPT cervical....

I have a quick question regarding the “intrathoracic surgery” on the procedures tab whenever you get time. We do NOT pick...

When a patient has an unwitnessed fall with possible head strike and the only injury listed is a headache by the ED RN may the..

How would you select yes or no to the question Is there hourly documentation beginning with ED arrival?

Would you consider this air embolism as a hospital event, Iatrogenic vessel injury? There was no further consequence of it...

For return to OR…. Does the patient physically have to leave the OR and return, or does the patient meet criteria if the...

When physician is charting a LOC throughout the chart but not specifically stating concussion, there was a term(s) that could..

Why does a “red flag” pop up if I document that the ED physician is present before the patient arrives? Wouldn’t that indicate..

If we have an insurance listed as “Amish under agreement” meaning that the Amish church/community that the patient is a part...

we have a patient who comes in frequently with burns from huffing keyboard cleaner. She had a documented history of “Inhalant...

Please help me with a code for “electric bicycle vs car."

Would you consider this patient PTOS? Pt was admitted to trauma OBS for over 2 days , assaulted with boxcutter and sexually...

I have a patient who was standing in the ocean when a wave knocked her over causing injury being captured in the registry...

Scenario: Patient is admitted as a trauma with a previous kidney transplant (2 years ago). However, they are in kidney...

I have a question regarding hospital event entry? We have a patient who was confirmed to have hospital event ( major...

If you have a patient that exhibits tremor, sweating, agitation, confusion and hallucinations with a document history of...

If it is an ambulance Helicopter rendezvous from scene to Hospital. Which is the correct way of documenting it in collector?...

If a patient is transferred out, even with no injuries being found at the transferring hospital, why would that not be...

I have a question about whether a patient in our registry should be PTOS. The patient I am doing is a transfer from an OSH...

The patient was getting into her car when her purse got hooked on the gear shift. The car began moving and rolled over the...

Am I mistaken that there isn’t one good code for an emergent bilateral clamshell thoracotomy that doesn’t have a further...

When Medical records state no insurance on file-I’ve been using Unknown for payor class, then would go back within 30 days...

We are now routinely updating collector data and resubmitting diagnoses after we receive our autopsy results. If we are...

I received an autopsy report today from a DOA to our facility from a pediatric abuse case. Since he was DOA we did not do any...

Bedbound Pt transferred from outside facility ED due to bruising on LE. Gets admitted to our ICU. Dx: Bilateral femur fxs...

Pts with Hx of COPD that may or may not be DNR, who have mechanism of injury, with AIS codes, admitted to Step Down or ICU...

I have the radiologist and the Trauma H+P stating there is a Lefort 2 fracture but upon review of the AIS book I don't have...

I have a patient that was an unwitnessed fall with head strike that came to the hospital via POV. The patient was made a....

I just wanted to check to make sure that there is not a problem with our Data submissions. The status usually says...

NS called while in the ER and the PA responds while in the ER but the MD does not see the patient until the next morning on...

What would you do in this situation: Paramedic on board – you’d pick up ALS as highest level of provider Patient was offered...

Can you please clarify the Cardiac Arrest with CPR Hospital Event?

Question, for transport accidents ( pedestrian VS MV; pedal cyclist VS MV) with no documentation as to where they occur (on...

Could you provide guidance as to if this patient should be picked up as a PTOS patient or not. Scenario: Patient was at a...

I have a question regarding PTOS inclusion regarding a DNR case. Patient presents with neuro symptoms and CT reveals head...

I’m wondering if you can help us with an inclusion question. Should a patient who was already seen, treated for their injury...

We had a patient transferred in to our hospital: • Cardiac patient admitted at outside facility • Fell in the hospital and...

If I don’t have MR for referring facility but I have a PCR that has vitals on while the patient is still physically in the ED...

We had a pt come in after an MVC and when the initial CT of the head was done, it showed a small SAH. When his repeat within...

I am in a bugger of an OR report, and struggling with the awful “control vs. more definite root operations” guideline....

Could you please tell me what all “spinal cord injuries” we capture when we answer yes to the sequential neurological...

While running reports looking for ambulance/helicopter providers, we noticed that there are a few from New Jersey. Can other...

In Outcomes, records will fail to import if there isn’t a descriptor w/ the EMS agency or destination facility. So for...

I have a case where the pt. was at another trauma center, developed pneumonia, unplanned intubation, sepsis, ARDS, and major...

I have a peds patient who was in a golf cart accident with head injuries. I have defined SDH and skull fx injuries. One....

6/7 he has an aspiration event that caused respiratory arrest. During intubation “abundant emetic content in the vocal cord...

How are we to abstract a pregnant mother and baby injured in a MVC if the baby dies at the hospital after delivery?

We have someone treated at another hospital and discharged. Now at our hospital ( for 1st time) requiring treatment for the...

I’m having a hard time with making this one particular patient a Non PTOS. Patient went to XXX Hospital for an...

Does the "Did patient have a craniotomy for trauma?" element include craniectomies?

Some of our patients for weird re-occurring subdurals may require treatment by way of MMA embolization. Can you confirm that...

I have a clarification question regarding ICH with word “lobe” in the Dx description, and wanted to make sure correct codes...

If I have a patient who has a GSW to his arm and the OR record indicates Brachial Artery Thrombosed x 2 and the OR surgeon...

We are looking to properly code a person who fell off a treadmill while the patient was running on it. The location was in...

A question came up regarding when a patient comes in from a Skilled Nursing Facility and then is discharged back to the same...

I have difficulty building reports in Report Writer. Is there something out there with step by step instructions?

We code our head injuries according to their CTH scan closest to 24 hours. This is not, at times, the worst CTH...

We have a patient being discharged to XXX Hospital – XXX Behavioral Inpatient Hospital. They are not listed in that...

We are receiving a Level 2 Error for Highest GCS in our TQIP submission. The ACS has informed us that a patch was sent to DI....

Was wondering if we could use clinical data from a transport pcr that was at bedside of patient when the first vitals were...

6/7 he has an aspiration event that caused respiratory arrest. During intubation “abundant emetic content in the vocal cord...

We have a patient transferred in from an outside hospital where he was seen for complaints for aches & pain. A CT of the head...

How would we answer the "was unplanned reintubation required within 48 hours of extubation" element for a patient that went...

I have written down in my notes to enter codes for drainage and monitoring for Ventic procedures per the ICD Q&A. We were...

I am working on a record that has documentation that the pulmonary contusion is located in some aspects of all 5 lobes. Per...

I am reading in the manual on page 16 about iatrogenic injuries not meeting the inclusion criteria. We had a person who fell....

Question, patient arrives to the ER with CPR in progress and PEA documented... so what is my answer for P,R,B/P? would it be...

We are having trouble abstracting the Functional Status at Discharge elements. Are these FIMs? If so, why is the scale....

We have a question about a possible unplanned ICU admit. The patient came in with epigastric pain and other cardiac...

I have always been stumped by a trimalleolar fx diagnosis...

We have a question to ask in regards to unassisted resp rate (page 97) a new highlighted field “Do not enter ‘0’ if...

Is a patient who resides at an assisted living facility considered a personal care home?

Can you confirm the first documented value for vital signs by EMS? 0, 0, 0 or 88, 0, 94 20:49 B/P 0, Pulse 0, RR 0...

I have a patient that was brought to our facility by EMS from a clinic due to an abdominal hernia. While the patient was in...

In reviewing the report from TQIP for missing BMI – at lot of patients heights are missing if they weren’t documented within...

Should be picking up “Gout” as Arthritis for pre-existing condition?

I researched my manual and determined that snakebites are not considered PTOS but I want to be certain. Is a patient that...

Pre-Existing condition of Advance Directive Limiting Care, I have the TQIP definition on pg 91 (2019 Admissions) that states...

We have always interpreted the sequential neurological documentation element to mean " was there a confirmed skull, ...

I have a gentleman who crashed his ATV and was impaled in the buttock. He was placed on Zosyn and vancomyacin for the...

I am coding this pt’s injuries and it is giving it an ISS of 75. Is this correct….wondering if you could take a look?

I have a patient on a riding lawn mower in the street that was hit by a car. After going through the ICD book on mechanisms...

We’ve had a question come up about using closed head injury. It is my understanding (and the AIS book seems to support) that...

I have a question regarding Acute Care field: DID PATIENT RECEIVE A CT SCAN OF THE HEAD DURING THE RESUSCITATIVE PHASE?...

We have had an issue for the past two days while attempting to transfer records. We have had 8 records that fell out due to...

On the EMS Trip Sheet we have the times listed all the same would we use unknown for all or use the called time...

The EMS Trip Sheet has no box listed for Trauma Criteria and we have new drop down selections under NTDB...

If the providers are ALS and service states ALS but note nothing in the description details about providing ALS care do we...

Page 177. Codes for REBOA , what is the definition for the word Temporary in this scenario?

Page 138. Was mass transfusion protocol initiated? We are assuming there is not a number of units of blood required with this...

I understand to exclude isolated hip fxs with no other injuries besides contusions and abrasions, but what about...

If we enter an EMS affiliate number that is not stored in Collector it gives an error message on V5. So is it best to add...

Please help us to clarify how to handle this situation. We had a patient brought in (pedestrian struck) who was resuscitated...