Note that there are differences between PTOS (PA) and the NTDS/TQIP in how COVID is captured. For PTOS, I recommend recording 3=not tested. This is because PTOS’ COVID element is specifically related to PCR testing. For the NTDS, you can capture COVID within the diagnoses since you do have physician documentation.
I have a patient that had physician documentation of having covid within 30 days of her admission to us. I do not have any test results just the physician documentation that patient was diagnosed with Covid within 30 day of her admission to us. Based on this would I enter this as a dx and answer the question of covid 19 result status as unknown?
The following should be included:• PTOS Patient = Y• Did the Patient have a craniotomy for trauma = Yes• Craniotomy procedure ICD10 is detected:o Any Operative procedure (PR_01_I10…PR_84_I10) = that starts with 0N [8,9,B,R,T,U] [0,1,2,3,4,5,6,7,8,C,D,F,G,]0 OR00[8,9,B,C,Q] [0,1,2,3,4,5,6,7,8,9,A,B,C,D]0• AIS Codes between 140630 and 140636 OR AIS codes between 140650 and 140656
Unfortunately, we do not have that information. We recommend you check with your financial, HIM, or billing department as insurance can vary regionally. These would be the best sources.
I have a patient who is admitted to the hospital and undergoes a COVID screening the same day which is negative. Two weeks prior to the patient’s admission they had a positive COVID testing. What do I record in the custom PTSF field? Should I send the question to NTDB to see if it should be included in the dx? I checked the guidelines and can’t find anything in the 2021 guidelines on covid or the guidelines.
For the PTOS, we recommend you record NO. While we do accept test results from prior to admission, a negative test on arrival at your hospital should be recorded with a NO response for the COVID-19 data element. We also recommend you do reach out to the NTDB for clarification regarding their specific COVID-19 data …
The intent is not that this code be excluded. Part E essentially means a procedure code of 5A19_5Z is captured in the record.
You are required to have a plan for IRR, but PTSF does not have any specific required process or number of records for IRR. It can include full record reabstraction or focused review. Reabstraction can be done by one or all registrars. Some ideas include: • Full reabstraction of record by one registrar • Full …
DI was acquired by ESO in December 2019. There is no longer an annual DI conference you can attend. ESO does hold an annual conference called “Wave.” For 2021, this conference is in the form of a webinar series; however, it is typically held in person. ESO will not be presenting education at the 2021 …
We currently have a patient admitted and undergoes a COVID-19 screening. Patient answers “yes” to the question, have you had a positive COVID-19 test in the past 20 days? For the PTSF field it states COVID19 test result available to answer yes or no. Do you need the actual test result or the hear say of patient answering is when screening is conducted? We are also seeing documentation within the physicians notes stating the patient’s were tested within the 30 day time frame with either a negative or positive value, however these patients were tested outside with no results available/viewable in patient’s records. Without the actual test value result within the record would this be insufficient to capture a value in the COVID element?
If a physician confirms a positive or negative test result within 30 days, we would accept that documentation, and you can record a yes or no value for the COVID data element. We would not accept hearsay from a patient or family member etc. without physician confirmation.
Our patient was not a transfer into us, but we can see other hospital EMR’s scanned into care everywhere in Epic. Is it a HIPPA violation to view that other facility chart? Or can we since it is part of care everywhere in Epic? If I can use the other facility chart, what information can I use?
PTSF cannot speak to what you are allowed to access or what the appropriate use is for Care Everywhere in your facility. Proper access and use of an outside facility chart in a shared database in Epic is something you will need to discuss within your facility. Specific to elements that you might abstract from …
With no secondary payor, you can now enter “9 None”. This is a new option to report for 2021 admissions instead of n/a or leaving blank.