FAQ's

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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...

EMS ambulance was on its way to LZ at XXXX Hospital from the scene, they arrived a few minutes before helicopter...

What is the process for records that initially were identified and abstracted as PTOS and transferred to you, but really...

When is PA slated to transition to AIS 2015?

We have a patient who has an epidural hematoma within the posterior thoracic epidural space. It is very difficult to...

On the Validation Detail Report are LEVEL 2 ERRORS in the NTDX with the message “ Field should not be “Not Applicable” as the...

When running the Vendor Aggregator Process, 2 previously deleted cases are showing as LEVEL 1 ERRORS in the NTDX with the...

I have a question on LOC and GCS. Can the registry use when the patient is not following commands (best motor response < 6)...

Unless the patient arrives with a positive etoh level, how can you be sure of the time of the cessation of alcohol...

Discharge destination--patient was discharged to hospital outside the United States. He was transferred to Hospital General...

If a patient fell in their apartment at an Assisted Living facility Do we code it to non-institutional (private) residence or...

I have a question RE: a trauma pt that for some reason was not put in collector from Jan. It was just found that he was not...

I was always under the impression that if a patient leaves the ER for a diagnostic test (x-ray, CT scan) and does not return...

I’m having trouble deciding what to do with a chart I am working on.The patient was transferred from one outside facility to an

I was wondering if you could clarify for me more about Transfer Out in regards to PTOS status. For example, a patient arrives...

Can I send you an Operative Report for assistance with coding?

Question for you, is there a “best” code for replacing the partition of the skull that was taken off in craniectomy?

I am trying to code an electrical burn, and I cannot get an AIS code of 080000.2. Can you assist?

Can you provide some guidance on the following scenario please? Patient’s admit order was written at 4:26 but no beds were...

Scenario: You have a patient with an order written for ICU or Stepdown but there were no beds at the time. Patient holds in...

I have a questioning regarding a patient that we have. Patient admitted 12/21/2018. The patient continues to remain in our...

We recently received a patient that had an MVC. All hospital documentation states that the patient lost control of her...

I’m emailing you to ask about the status of our site’s recent uploads to PTSF. Including today’s submission, our last 10...

What is the email that we are supposed to send questions to? That way, we can send it correctly instead of sending them to...

Is there someone that can verify that the PAV5 outcomes files that I have submitted are done correctly?

In this example, is it correct to code “brain edema”? (see highlighted portion). In discussion with my nurses, I was told...

Bilateral subdural hematoma if one is tiny and one is large if we want to code both will only the large one interface to...

I have a patient who was rear ended while on a bridge. There is no location code for bridge, should I code it as unspecified...

I have a question about nasal bone fractures. Does it have to say open nasal bone fracture. I currently have a patient that...

Could you please clarify a question regarding Alcohol use disorder for comorbidities? Does it have to state “ disorder” to...

I am still working on the audit filters on the quarterly report and am confused with Filter 10 regarding patients with EDH...

When someone has for example, Highmark Medicare (Freedom Blue PPO plan 378), do you use #2—Medicare Managed Care or #6...

If a patient is intubated and sedated, do we still need documentation of motor power of extremities or documentation that...

Can you look at this scenario and tell me what you’d do? Patient came in on 03/06 @1703 after a fall from lift chair – dx...

We have noticed in the PTSF procedure section that the code for a Bronchoscopy with Lavage is listed as 0B9...

We had a 22 year old patient that was a direct admit to the Orthopedic Service last night that fell while doing a handstand...

I have a question regarding an occurrence. Wound infection. Patient was a GSW. On hospital day 8 he had purulent drainage...

Are you able to define what location is “the resuscitative phase” for audit filter 3a?

At XXXX Hospital, we recently noticed that when we put “unknown” for a patients date of birth that came in as a John doe...

I am working on a case for a patient that had a syncopal fall from a toilet at a restaurant on XX/XX/19. He was seen in ED...

I have a question regarding direct admits and the administratively discharged time. According to the Data Dictionary for...

If we have a patient with burns but our physician does not document a percentage and the patient was transferred out to a...

How do I register for a course on the new elearning site?

When a patient has a loss of consciousness but NO concussion or other traumatic injuries, would the LOC be coded?

We were discussing the Nutritional Assessment under the “Clinical” section. In the past it was verbally stated to us that...

Would rib plating for fracture stabilization be considered intrathoracic surgery for the Audit Filter #13?

Do you consider Cardiac Cath doctors Other, Surgical –or- Other, Non-Surgical?

I have a patient who went to a “VA hospital” and was sent to our facility for frost bite. Are VA facilities considered...

In looking at the new examples in the dictionary for Unplanned Admission to the ICU, we’re having some disagreements on what...

Patient was injured at an unspecified place, for simplicity purposes let’s just say it was home. He then walked to the EMS...

If a patient is on a floor and needs MAP goals monitored and the only place they can do that is ICU is that an unplanned...

A change this year was that EMS needs to state trauma center triage criteria and what it is. Some of our trip sheets do not...

A 3 year old got his finger caught in the hinge of an ottoman. The parents drove him to our ED where they found an open fx...