Frequently Asked Questions

There are no guidelines in the PTOS Manual that tell you not to use PACU as a post ed location, it just isn’t in the current menu as an option. I recommend recording 15, other, for Post ED Destination and specifying PACU in the Specify field that opens.

For Procedure Location, you can record 13, PACU.

If there is documentation and/or an order that the patient is a transfer out and is to report to a receiving facility, PTSF recommends this patient be captured as a transfer out. You may have other transfer out by private vehicle patients that do the same, stop somewhere, they just don’t tell you. It isn’t your responsibility to confirm the patient actually arrived at the receiving facility and when. As long as your facility ordered the transfer, you should capture the patient as a transfer out.

If, however, the direction was for the patient to go for follow- up (a scheduled surgery) later, then PTSF would recommend recording a discharge from the ED to home.

If the patient has multiple x-rays performed, there needs to be documentation of portable for all or documentation of the presence of the RN or CRNA, patient vital signs, and/or care rendered must be present for all x-rays that are not performed portable. If this is not the case, you should report 2, no, for this data element.

Fentanyl is recorded under opioids and should not be captured separately.  

That is for all studies, yes.

I recommend recording unknown as the determination of supplemental oxygen should be made during the assessment of the initial ED/hospital oxygen saturation level. In this situation the initial O2 sat is documented at 14:59 with no documentation of supplemental oxygen.

You are correct that you do not need to capture procedures for coexisting medical conditions. Only procedures related to evaluation and treatment of injury are required to be included in PTOS. However, if the blood products were given within first 4 hours after ED/hospital arrival, you do need to capture those volumes appropriately under the blood product data elements as there is not exclusion for medical conditions unrelated to the trauma for these data elements.

Yes, if an incomplete GCS is documented, record as many of the GCS items as are available. This includes the Total GCS. You may record individual scores with a GCS of 3 [1,1,1] or 15 [4,5,6] recorded in the medical record.

No, if Trauma is not called in ED, you would enter NO for “was alert called”, and just enter trauma consult call/arrive on the consults side. This is similar to direct admit scenarios.

Since the initial laparotomy began > than 2 hours of arrival to your hospital, the appropriate answer would be Yes-the patient required a laparotomy/laparoscopy and had the procedure performed greater than 2 hours of ED admission. Per the PTOS manual, it is the time the laparotomy/laparoscopy was performed. 

Since the head CT was completed at an outpatient facility, not a transfer in, the answer would be no for CT head done during resuscitative phase. Per the manual, Yes is only an appropriate answer if the patient is coming from a referring facility, or the scan was done from time they entered your ED to time transported to Post Ed destination. You can enter No as a transfer patient, but Yes data is available, in the Referring Facility tab. The CT scan can be entered there, but not on your hospital side. In review, the situation can be noted to explain why no CT during resus.

You are not to use data from the referring facility here. You must record the first height and weight documented within 24 hours of ED or hospital arrival at your facility.

You cannot record both a controlled and an uncontrolled rate in PTOS. The idea is that you are capturing the initial vitals. For respiratory rate, you are capturing the initial respiratory rate, which will be either controlled or uncontrolled.

If you are confident this information documented in the nursing notes is accurate, you can use it. I find it unusual it is not also documented elsewhere. I recommend you use caution and perhaps query the providers to ensure these medications were given to the patient.

First, I want to remind you that the sequential neurological documentation data element is optional and is no longer submitted to the central site. Centers now have the liberty to abstract this data element as they see fit for their institution, or not at all. In other words, this data element is a facility-specific data element, and is no longer part of the PTOS dataset.

If you would like to abstract this data element based on the definition that was applicable 2021 and prior, it does look like pneumocephalus is coded to the head region in AIS. Therefore, 1 (yes) or 2 (no) should be recorded for the sequential neuro data element. Option 3 for head or spine injury not present would not apply. I don’t see anything in the AIS coding guidelines that states pneumocephalus should not be coded in addition to a Lefort fracture.

Thanks for the question, that was changed after initial release. 

 If the patient was screened, then you will answer this question whether screening was positive or negative. 

Answer Yes, No, or Unknown, based on whether the patient was offered an intervention. For negative screens, it may be your practice that patients are not offered intervention so No may be your standard answer. It was changed to allow cases in which the screening may have been negative, but providers offer an intervention, perhaps based on other information.  

The N/A (or inappropriate) option may be available because of how the software works, but if it isn’t listed on the dictionary menu, then it should not be used. Do not enter N/A (inappropriate) in this element. 

Supplemental oxygen is determination of the presence of supplemental oxygen during assessment of initial ED/hospital oxygen saturation level, so it is asking if they had supplemental at the time of the saturation measurement. If you don’t see it then, and see it later, it may be not what was in place, so answer unknown for supplemental.

Great questions! For GCS-Eye Opening, the assessment is of the stimulus to induce eye opening, not the vision itself. As stated, you have documentation of GCS 15 and that would be appropriate to capture. For Pupillary Response you would record neither reactive. This aligns with the guidance in the NTDS Data Dictionary that states, “Field value 2. One reactive should be reported for patients who have a prosthetic eye.” Since the patient has two prosthetic eyes, you would record neither reactive.

This scenario falls under W01.0 (tripping over animal). W01.0 does fall within the accepted code range for our solitary hip fracture exclusion. Therefore, based on the information provided, this patient would meet the exclusion and would NOT be captured as PTOS.

You don’t need the term “TBI” if you have a specific diagnosis of brain, skull or scalp injury (can be open or closed) , as long as it caused anything from drowsiness to an intracranial bleed. So just diagnosis of SAH is fine; if you get into milder skull/scalp injury I would want to see that at least drowsiness or concussion symptoms were noted.

We recommend to always record the mechanism that caused the most severe injuries first. In this situation, we recommend the mechanism code for the strike by train as the primary and the mechanism for the electrocution as secondary based on the information provided.

In order to capture this as a pre-existing, the patient’s advanced directive to limit life-sustaining treatment must have been present on their person on arrival or already on file at your center.

Mechanism of injury plays no role in the Pre-hospital Cardiac Arrest definition. This pre-existing condition should be considered for every PTOS patient regardless of their MOI or diagnoses.

In situations where patients fall in place while going up steps, we recommend recording a fall height of 0 = fall on same level. This is only true if their fall did not result in a fall down the stairs. For mechanism in ICD-10, you will use the category for fall from/on stairs.

Please refer to the Best Practices Guidelines for abuse. If you cannot locate this resource, please contact PTSF staff, and we can provide it for you. I hope this document helps clarify abuse for you. This resource provides great information, and best practices for abstraction as well.

Any physical assault is not abuse. However, according to ICD-10-CM coding guidelines, adult and child abuse, neglect and maltreatment are classified as assault. Any of the assault codes may be used to indicate the external cause of any injury resulting from the confirmed abuse. For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y09) should be added to identify the cause of any physical injuries. A perpetrator code (Y07) should be added when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code. Lastly, if the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent.

Regardless of an assault or abuse as the presenting injury, you will answer the element “was the patient being evaluated for abuse as “yes” as long as the patient has a workup for physical or sexual abuse at your facility due to the presenting injury event. To code mechanism of injury correctly when abuse is suspected or confirmed, you will need to follow the guidelines in the reference document mentioned above and the current PTOS Manual.

Any previous head injury that caused anything from drowsiness to severe injury. When we say “A TBI must be clearly documented” this means any brain injury, so SDH qualifies. You do not need the actual text of “TBI”. You would often only see that wording if they don’t get a diagnosis.

In these situations, Height of Fall is recorded with an I for inappropriate. You can record any additional information you wish (excluding patient/provider specific information (PHI)) in the Cause of Injury Specify field.

Per ICD-10 guidelines, SUV is included in the same category as pick-up truck or van. Although Jeep is not specifically defined in ICD-10, I recommend including Jeeps in the SUV/pick-up truck or van category.

No, PTSF does not recommend capturing Functionally Dependent Health Status with documentation of a prosthetic eye as a prosthetic eye is more aesthetic than functional.

D.08 is not limited to the three listed, those are examples. I could not find the specific reference document on the ASH website either, but we’ve understood that this list is not all inclusive.

The NTDB FAQ’s does tell us to report bleeding disorder for thrombocytopenia. It is for any condition where the blood does not clot properly.

Hookah is not reported. The pre-existing condition Current Smoker excludes pipe, cigar, or smokeless tobacco (including vapes or e-cigarettes). Hookah is a type of pipe.

Great question! This would not be considered a transport accident. To capture that (pedal cyclist injured in nontraffic accident), the device assigned primarily needs to be for conveying persons or goods from one place to another. Fall from one level to another would work best in this situation.

Interpeduncular cistern does code to brain stem. In the AIS clarification document from October 2019 they have
“Interpeduncular fossa (cistern) basal cisterns code as injury involving hemorrhage in the brainstem;”

The ICD-10 code has hemorrhage of brain stem also.
I would note any specifics related to LOC if you have documentation, as it will assume the LOC nfs otherwise.

If you have an AIS code recorded that falls within the defined coding criteria for these fields, you will need to answer the antibiotic elements as if there is an open fracture present for both PTOS and the NTDB. This criteria is provided by the NTDB/TQIP, and we understand sometimes it is not perfect as some non-open fractures do get included simply based on how they are coded in AIS. PTSF can provide the current list of AIS codes that fall within the criteria.

This could be used to code cerebrum brain swelling. Partial effacement would go to moderate; compressed – 140664.4, while complete effacement would go to severe; absent/obliterated/closed – 140666.5. I wouldn’t use edema unless the provider notes as edema.

Correct. You are to code brain injuries based on what is documented closest to or at 24 hours, or at initial confirmed diagnosis if later than 24 hours. If a head bleed is noted after the first 24 hours, that would be considered the initial confirmed diagnosis and you would capture the injury.  

The guideline states, “coding of brain injuries should be done at 24 hours or at initial confirmed diagnosis if later than 24 hours.” Since the initial brainstem herniation was not initially diagnosed until after 24 hours, you can code it based on the information you have when the diagnosis was confirmed.

The S73 code has an Excludes 2 note, excluding dislocation of prosthetic. So if all that is dislocated is the prosthetic, it directs to use the T84 code, which does not qualify for inclusion. Excludes 2 means there could also code S73, if there is injury to anything (hip) other than the prosthetic.

If it is present on arrival, for the purposes of diagnoses, you can enter up to 35 c. You are correct that this is different from the hospital event definition.

Pathologic, chronic, age-indeterminate, stress, and traumatic fractures are all coded differently in ICD-10; only traumatic codes are included within the PTOS inclusion criteria.
AIS has clarified that osteophyte/bone spurs are not to be coded. We default to AIS rules, so osteophyte fractures should not be included.

The 24 hour rule applies to capture size of the injury, as close to or after 24 hours, to capture the “full” size of the injury. If you have an injury that isn’t identified in the first 24 hours, you would code it when it is identified. However, this does not include anything due to the treatment. So if size is impacted by treatment, go with the size prior to treatment, but any new injuries, not related to the treatment, would get picked up.

You won’t code separately any laceration that is part of the open fracture, with the wound and fracture communicating. You should go ahead and code the procedures, yes, it is okay that there is no separate laceration diagnosis. It is understood that an open fracture has an open wound (or multiple) associated.

Hypothermia that is present on arrival and not related to treatment or sequela is coded. You would capture this as 34 degrees since you are not rounding up or down. Hospital event for hypothermia in the PTOS manual reads less than or equal to 34, so 34.2 would not qualify for a hospital event.

Yes, if the injury occurs after the patient is in your hospital being treated, then that is not a qualifying injury.

The idea is that those patients are being reviewed through another quality review in your hospital, so are not picked up for PTOS or NTDS.

That’s correct. The patient was discharged home from the ED. She went home and did not meet LOS and so does not qualify as PTOS.
In order for Stepdown or ICU to be qualifying criteria, the patient actually has to go to the unit.

No, if the injuries are due to the disease then you won’t pick it up. Another example would be osteophytes on a vertebra. You can pick up a fractured vertebra, but not a fractured osteophyte.

It all comes down to the ICD-10-CM diagnosis code. Lacerations do typically fall within our ICD-10-CM inclusion code range. It is the superficial abrasions and contusions that are excluded.

If the patient has an ICD-10-CM diagnosis code that falls within the PTOS inclusion code range AND the patient meets another portion of the criteria (i.e. LOS, transfer, etc.), the patient should be captured as PTOS.

Treatment vs no treatment or medical admissions no longer play a role in determining inclusion.

Yes, the code W18.2 is not in the exclusion list and so would meet PTOS criteria.

When the patient is made CMO prior to meeting PTOS then they are excluded. So with your patient in the ED, assuming they haven’t met the LOS requirement prior to the determination for comfort measures, then they would be excluded.
If your patient was in the ED for extended time and met LOS before they went to CMO, then they would be included.

‘Admission to’ for our purposes can be admission to a hospice unit, service change, or just the status change/order for CMO, palliative care, hospice.

There is currently no flag for the NTDB/TQIP or a check in PTOS that generates if the injury date/time is unknown regarding the 14-day requirement. Therefore, it is the default that patients with unknown injury dates and times are to be considered for inclusion. If the patient has a documented injury that falls within the ICD-10 inclusion code range and meets another portion of the criteria, they should be captured as PTOS.

No, not necessarily. If they are saying this is osteoporotic, and therefore pathological, then no it wouldn’t be PTOS. That could get coded to M80.08XA, Age-related osteoporosis with current pathological fracture, vertebra OR M80.88XA, Other osteoporosis with current pathological fracture, vertebra. Neither of those two codes are in our inclusion.

In order to qualify for PTOS, it has to be determined as a traumatic fracture, not pathological. Then it would be assigned a traumatic fracture code in the inclusion criteria. You may need to query your surgeon for determination.

These are tricky scenarios, and clarification is typically needed from the provider in order to make a determination. We recommend querying the provider for clarification on whether this is a traumatic or pathological fracture.

No, this patient won’t be PTOS if the injury happened in your hospital while they were a patient. They do not need to be officially admitted, may be in ED or observation.

: Since this patient is a transfer in, you will include this patient as PTOS. A patient that meets the PTOS inclusion criteria prior to the order for hospice care, or the equivalent, should be captured as PTOS. If the patient would have come directly to your facility, they would have been excluded.

The reason for this inclusion/exclusion guidance is to ensure consistency statewide. It is our hope that this guidance will eliminate hospitals making differing determinations using variables that are not part of the inclusion criteria.

You only need to pick them up if they still have a qualifying injury diagnosis. If the patient has a diagnosis that falls within the inclusion criteria code range (lacerations are included) and meets another portion of the inclusion criteria (i.e. LOS, ICU admit, etc), they should be captured as PTOS. If the lacerations are resolved and not documented as an “active” or “current” diagnosis, you could exclude the patient because they would not have a diagnosis that falls within the inclusion code range. Note, cellulitis does not fall within our inclusion code range. If just cellulitis is documented, the patient would be excluded.

This is a good question. Since the abrasions are not injuries that fall within the accepted PTOS ICD-10-CM code range, this patient should be excluded from PTOS.

Note the following isolated injuries are excluded from PTOS:
S00, S10, S20, S30, S40, S50, S60, S70, S80, S90, *T68, T71.1 and T75.1 are excluded if no other
injuries are present

If the patient would have had hypothermia along with an injury that falls within the ICD-10-CM code range listed in the PTOS inclusion criteria, the patient would be captured as PTOS.

I agree with you capturing this patient as PTOS and recording them as a transfer out since all of your documentation appears to indicate the patient was to go to the OSF via POV. Starting with 2021 admissions, the requirement for patients to go from one acute care facility to another via EMS or air ambulance was removed. Patients transferred in/out via private vehicle are now included in the transfer in/out criteria. Whether the patient makes it to the OSF or not is out of your control.

The patient would be NPTOS for the second encounter. This applies to existing injury and newly identified injury attributed to the same traumatic event.

Yes, these are the challenging cases. The idea is to exclude patients for whom your team has ruled out traumatic injury. If your team is transferring and has not ruled out injury, then include them. For example, you may not do imaging on peds patients that transfer out, the receiving facility will do it and you are trying to limit exposure for the kids. If you are sending them thinking there may be injury, they are PTOS for you. The determination at the other hospital may be different, but that is not a factor in your decision.

There is not a specific black and white rule to follow. These types of cases will need to be determined on a case by case basis.

That’s correct, any time in ICU (plus a qualifying diagnosis) is PTOS. Assuming your patient has a diagnosis, they would be picked up as PTOS.

These exact scenarios are why PTOS previously excluded transfers via private vehicle as transfer patients. However, per the current guidelines, yes, this patient would be considered a transfer in as long as the documentation supports that the patient was to go via private vehicle from the OSH to your institution.

That is correct! The patient meets the criteria because they were injured within 14 days of the initial hospital encounter.

Fall in (into) shower or empty bathtub is coded to W18.2XXA. This code does not fall within the solitary hip fracture exclusion; therefore, the patient should be considered for PTOS.

It depends on when the determination for hospice/comfort care is made. Transfer In is a qualifier, but specifically for hospice, if the determination for hospice/comfort care is made before patient leaves the ED, the patient should be excluded. If the patient went to a ward/unit/OR/post ED destination before the hospice/comfort care was ordered, they are included as PTOS.

You are correct. The patient fell from a standing height (even if not fully upright) and was no longer in a seated position putting it in the exclusion criteria for solitary hip fx.

 This patient would meet inclusion criteria as along as she meets the other qualifiers as well (diagnosis, length of stay…etc.) Your thinking is correct that the patient was not in active care.

For the specific injuries noted age indeterminate, you are correct, you do not code. However, your patient may meet PTOS. If you are transferring and have not ruled out traumatic injury, they would qualify. So a patient with a mechanism, the abrasions, etc., and sending out, unless your providers are saying there is no injury, they could meet PTOS.

Great questions! This would meet PTOS criteria due to the inclusion of the scalp lac and the ICU stay. This would be considered a direct admission because they bypassed the ED. For scene provider you would choose walk in. Let me know if you have any more questions!

If they don’t have an acute injury that qualifies, they won’t get picked up as PTOS. If they have surgical dehiscence, plus additional qualifying injury, then they may meet PTOS. Your registry may still wish to include as nonPTOS.

If your facility has recorded a positive test on the patient, then record positive. With patients now being tested multiple times during their stay, if they test positive at any point, you will record a positive result.

With physician documentation of a false positive, and negative test results following, you will enter negative.

With patients now being tested multiple times during their stay, if they test positive at any point, we are directing to record a positive result. If you did not have the physician documentation and negative result confirmation, then you would have reported positive.

You are correct that TRISS will not calculate for every patient. TRISS EOE, which is a Pennsylvania specific estimated TRISS used in these situations, is planned to be included in the next software platform.

Your best practice is to delete the second record entirely, and not reuse the number. If it was already copied over into v5 with the interface, then you want to delete it there as well. If you haven’t submitted to us yet, we will not need to delete here. But before you delete, ensure that you do change it to NPTOS, just in case it would still be in the system when the transfer process is run.

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.

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 the previous encounter, you can use pre-existing conditions that are documented if you do have access to outside facility charts. You could also capture referring facility information. Note that these fields are specific to facilities that send the patient directly to you. This can be an acute care hospital or a non-acute care facility, for example, an urgent care or residential facility. For these non-acute care facilities, you must answer NO as a transfer. You also do not want to include information from all facilities and providers. You must only record information regarding the care provided just prior to coming to your facility. EMS information is also something you may have access to within this system. Be sure to record the scene, transport, and/or interhospital transport information appropriately by following the definitions provided in the PTOS Manual.

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.

The intent is not that this code be excluded. Part E essentially means a procedure code of 5A19_5Z is captured in the record.

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 collection requirements.

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.

The financial assistance gives free or discount, based on income, but if there is money due, they still pay it, so it would be self-pay. If primary insurance is self-pay, then secondary is None. In the comment field for primary, you could enter FAP, if you want to track it.  

Ablepay is a product which provides bill collection for the hospital (they pay the hospital a cheaper rate and take over collection like a collection agency). It also allows patients to sign up ahead of time, and make payment plans, but the patient still pays, so that is recorded as self-pay. 

Please make sure you grab the transfer and retransfer logs which will either be named transferred transfer.log/retranfer.log or will have the name with the file extension name .tl or .rl. Please contact Gaby Wenger and give her the list with an email of issues you are having. *Please add the logs with your email so we have the correct numbers that are being submitted* 

In order to capture any hospital event, including osteomyelitis, the condition must have occurred during the patient’s initial stay at your hospital. If the patient arrived to your hospital with osteomyelitis, it should not be captured as a hospital event.

For patient intubated for airway protection per MD documentation, you would not pick up unplanned intubation.

If this was a missed injury, meaning the injury presented itself but was not identified by the medical team, you would capture the Hospital Event. In the definition, patients with an unplanned operative procedure are captured. Also, even if this bleed didn’t present itself and could not be diagnosed until later in the stay, you will still capture this Hospital Event. The PI process can further explore and explain.

Yes, if it does not meet CAUTI and does meet UTI, pick up UTI.

If they meet the definition of the occurrence, you will pick it up and report for PTOS. There are no exclusions related to COVID, it can be addressed in review.

Based on the information provided, AKI should not be reported. The patient did not have an abrupt decrease in kidney function that required the CRRT nor were they diagnosed with an AKI.

You are correct. Unless there is documentation that the provider provided appropriate therapy for a urinary tract infection, you will not capture this as a hospital event.

There must be documentation of inhalation of gastric contents or other materials and then also documentation of clinical and new radiological findings of pneumonitis which requires treatment within 48 hours.

For PTOS you should report 17 (Hospice) for discharge destination. We want to capture the level/type of care. You can note “home” in the specify field. Note, the NTDB follows different guidelines in these situations.

In this situation you would enter unplanned visit to OR. PTOS aligns with the NTDB/TQIP for this Hospital Event. The NTDB has addressed within their FAQ’s that iatrogenic injuries are not excluded within this definition.

PTOS aligns with the NTDB/TQIP for the Unplanned Visit to Operating Room Hospital Event.

If the initial plan for the patient included conservative management, and no surgery, but the patient declines and ends up needing more aggressive treatment and is taken to the OR, you would capture the Hospital Event Unplanned Visit to the Operating Room for PTOS as well as the NTDB/TQIP.

The only exclusion is for “pre-planned, staged and/or procedures for incidental findings.” Really, unless the OR is part of the patient’s initial plan, or the procedure is planned to explore further potential injuries for example, you will capture this hospital event. If you remember, the definition used to only capture re-admissions to the OR. Capturing all “unplanned” operative procedures is relatively new.

If you have concerns about the definition and would like to recommend that an exclusion be added to the definition, I recommend you submit a request through the NTDS Revision Site at https://web5.facs.org/ntdsrevisions.

Yes, if they went to ICU post op, but it was not decided until after surgery started, then it is unplanned ICU.

The NTDB has a couple questions on their FAQ that are similar. They are under “Unplanned Admission to ICU” if you scroll down the 2021 FAQ. The link is https://www.facs.org/quality-programs/trauma/tqp/center-programs/ntdb/ntds/faq/2021.

PTSF recommends you capture both separately. That means spine would need to be recorded under the “other” option. Note that only Speech Therapy, Occupational Therapy, Physical Therapy, and Physiatry consults are required to be recorded for non-burn patients at a burn center and all patients at non-burn centers.

Based on the information provided, it sounds like the patient’s tracheostomy procedure was not initially planned. Therefore, I do recommend capturing Hospital Event 212 for Unplanned Visit to the OR.

Please refer to the Best Practices Guidelines for abuse. If you cannot locate this resource, please contact PTSF staff, and we can provide it for you. I hope this document helps clarify abuse for you. This resource provides great information, and best practices for abstraction as well.

Any physical assault is not abuse. However, according to ICD-10-CM coding guidelines, adult and child abuse, neglect and maltreatment are classified as assault. Any of the assault codes may be used to indicate the external cause of any injury resulting from the confirmed abuse. For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y09) should be added to identify the cause of any physical injuries. A perpetrator code (Y07) should be added when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code. Lastly, if the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent.

Regardless of an assault or abuse as the presenting injury, you will answer the element “was the patient being evaluated for abuse as “yes” as long as the patient has a workup for physical or sexual abuse at your facility due to the presenting injury event. To code mechanism of injury correctly when abuse is suspected or confirmed, you will need to follow the guidelines in the reference document mentioned above and the current PTOS Manual.

All events must occur after arrival at your hospital. If the aspiration occurred prior to arrival, it would not get picked up. If it occurred at a receiving facility, it would be on the receiving facility hospital events. It would get picked up at your hospital only if it occurred after arrival at your facility. Lastly, treatment must be within 48 hours of the aspiration.

NTDB has just confirmed to us that operative procedures do not need to occur in the OR, it is not tied to location. Their response was, “Some operative procedures are performed outside the OR. If the patient had an unplanned operative procedure you must report Element Value “1. Yes” to TQIP for the Unplanned Visit to the OR data element, regardless of the location.”

There is no time limitation in the definition; therefore, if there is documentation the patient had substance use disorder at any time you must report the Hospital Event Substance Use Disorder. This is true even if there is documentation the patient is in remission.

There is no exclusion within the definition for the Hospital Event Unplanned Visit to the Operating Room for these situations. Therefore, I recommend you capture the hospital event in the registry.

In this situation, we recommend you NOT capture the unplanned OR hospital event.

Currently, in order to capture a consult, the provider must be physically at the patient bedside. I recommend using the phone consult data elements to capture these teleconference visits.

This would meet ambulance/helicopter rendezvous, as both provided part of the transport from the referring facility to you.

You may enter 1, yes. It sounds like you have documentation from the non-acute care hospital. If this is the case, you will enter 2, no, for is this a transfer patient element. But you will then enter 1, yes, for documentation available from outside facility on the Referring Facility tab.

If the x-ray is for the hip specifically, I recommend using the BQ0 code. If it is a diagnostic x-ray that is of the entire pelvis that happened to identify a hip injury, that is when I would use the BW01ZZZ code.

If you would like to send over the documentation you have, we can take a look and offer a better recommendation.

You are to record the first assessment of each vital sign after the patient leaves the facility.   

It sounds like you have two separate encounters here. The first, I’m assuming, is nonPTOS as the patient most likely left AMA prior to meeting a portion of the inclusion criteria (i.e. LOS).

The second encounter should be captured as a separate trauma record that will be PTOS. Information about the injury itself will remain the same; however, arrival information and care information should only be recorded in Collector based on the second encounter. For PTOS, you will enter the scene information based on the EMS provider who took him from his home to your center. I would encourage you to enter some information regarding the first encounter with this patient in your notes/memo sections of Collector. If you complete information in the yellow memo section, please remember to exclude any patient or provider identifying information as that information is sent to us at the central site.

The PTOS Manual provides examples of common paralyzing drugs under the Paralyzing Drugs data element. Rocuronium is included within these examples. Under GCS qualifiers, I recommend Rocuronium be recorded as a paralyzing drug and Ketamine be recorded under sedation. Note that each of these agents has a slightly different duration of action (as you mention), so their effect on the GCS depends on when they were given. You will only record Chemically Sedated or Chemically Paralyzed as a “yes” for the GCS Qualifiers data element if the drug was affecting the patient at the time the GCS score recorded was assessed. You will need to work with your trauma program to make that determination.

There is no specific timeframe. While intent is to document if there is a delay, there does not need to be a delay to report extrication.

We recommend using walk-in as the scene provider and recording the time of injury as the admission date/time. This allows for abstraction to really begin with the injury/fall and not with their initial admission at the referring facility.

You are correct in your thinking! Extrication is defined as any action that disentangles or frees from entrapment or delays in transport. Since the fire department rescued the patient from the building fire, this would qualify as yes for extrication. The primary intent of this element is to give a reason for delays in transport. However, a delay in transport does not necessarily have to occur for there to be an extrication.

I would look for the hospital documentation first, using the latest time from the hospital, and using EMS time if you cannot find documentation of time left, or if it is illogical. We added the option to use EMS time because often the referring facility records are missing data. If the times seem incongruent, you may need to make a call to use the EMS time. If the difference, however, is just a few minutes, as you noted people look at different watches, then I would use the hospital data.

You will report “1 Yes” if the procedure was done at either the referring facility or your facility within 24 hours of injury.

This is a great question, and PTSF staff can’t find a specific code. We recommend root operation extraction, and then skin, or subcutaneous (whichever appropriate).

If you mean as a procedure code, drainage device is the 6th character, used for foley catheters, and would be appropriate for condom catheter. I would assign different codes for these. 

Foley catheter would be 0T9B70Z, for drainage, bladder, via natural or artificial opening, drainage device 

Condom catheter would be 0T9DX0Z, for drainage, urethra, via natural or artificial opening, drainage device 

I wouldn’t code to bladder for condom catheter, as it is technically just draining the urethra. This is an external urinary catheter, so we want the external approach as well. 

Yes, the 6^th character of “L” is for fresh plasma, so that is what you would use. “K” is frozen plasma. The other characters depend on other things (peripheral vein vs central, etc.).

If a procedure is unable to be completed, code to the furthest step completed. If reposition is not achieved, you could code immobilization, or traction, or inspection, whatever piece was actually achieved. For the ultrasound, in your example, the scan was completed, they did the scan, they just didn’t see what they wanted. But you would still code the ultrasound. If they stopped the ultrasound before completing the entire region, then you could code the part done. For example, they start a FAST, which is abdominal/pelvic, cardiac, maybe pleura. If they see the spleen, and then stop without scanning entire region or anything else, just code to spleen. To consider an image procedure not done, it would be that the patient went there, maybe got on the table or started but immediately stopped, perhaps patient condition changed and they couldn’t do it. In that case, you do lose the procedure.