Target Summary

Procedures

This module is designed to consume well-known procedure codes such as CPT and ICD. This data is important to MPOG as it allows researchers to easily identify operations and other procedures. These codes are commonly found in an institution’s professional fee and hospital discharge billing systems.

Target Summary

Column Name Data Type Description Global_Patient_ID string Cross-system patient identifier, typically MRN Patient_ID string Local patient identifier Visit_ID string The visit or stay during which the procedure occurred Operation_ID string The operation during which the procedure occurred Invoice_ID string The invoice the procedure was charged on Procedure_Code_ID string A unique identifier for the specific charge Procedure_Source_Type string Professional fee vs. hospital discharge Date_of_Service_Start datetime The time the procedure occurred or started Date_of_Service_End datetime The time the procedure ended Date_of_Admission datetime The time when the patient was admitted Date_of_Discharge datetime The time when the patient was discharged Procedure_Code string The actual procedure code (e.g. 00222) Procedure_Lexicon string The dictionary the code belongs to (e.g. CPT) Procedure_Code_Priority integer The relative importance/rank of the procedure Was_Primary_Procedure boolean True = Primary, False = not primary, null = unknown Total_Anesthesia_Units integer Total anesthesia units (for anesthesia charges only)

Examples

The following link will open an Excel spreadsheet that describes a few possible results sets that the adapter can return. These results sets are meant as guidelines and do not represent requirements. You should return as much data that exists in the data source.

Procedure Examples

Note that the spreadsheet contains comments scattered throughout the result sets. These comments might provide helpful insights into how adapters can differ. Also, the spreadsheets contain randomly generated data and therefore likely won’t make sense.

Column Descriptions

Highlighted descriptions indicate columns that are generally important to the MPOG importer. It is a good idea to include these whenever possible.

Global_Patient_ID An identifier used to identify the patient across the institution. Typically this is a medical record number.

Patient_ID

1 An identifier from the source system that uniquely identifies the patient the procedure was performed on. Patient_ID can be the same as Global_Patient_ID if the source system uses the same identifier (e.g. billing systems commonly use MRN to identify patients).

Visit_ID An identifier that links the procedure code to a patient visit. If your system does not support the “visit” concept or this link is not explicit in the data, this can be left blank.

Operation_ID An identifier that links the procedure code to a specific operation. This only applies to procedures that were performed during an operation. This field should be filled only when an EXPLICIT link is in the source system. See the “Do Not Create Data Links” section for additional details.

Invoice_ID The invoice identifier that the procedure code appears on. This obviously only applies to data from billing systems.

Procedure_Code_ID An identifier that uniquely identifies the procedure code in the source system. Procedure codes should be unique across patient, time, and procedure code. If no such identifier exists leave this field blank.

Procedure_Source_Type Describes where the data originated. This column will be mapped to several MPOG concepts that include “Anesthesia Pro-Fee Billing”, “Surgery Pro-Fee Billing”, and “Hospital Discharge Billing”.

Date_of_Service_Start The date and time when the procedure was performed. This can also represent when the procedure was started.

Date_of_Service_End The date and time when the procedure was finished. This generally only applies to time-based charges like anesthesiologists’ professional fee charges. If not available, this field can be left blank or use the same value as “Date_of_Service_Start”.

Date_of_Admission The date the patient was admitted to the institution.

Date_of_Discharge The date the patient was discharged from the institution

Procedure_Code The code representing the procedure performed. This is the one column that is required in all cases.

Procedure_Lexicon The dictionary from which the procedure code was taken. This field will be mapped to available MPOG concepts such as “CPT”, “ICD-9”, or “ICD-10”.

Procedure_Code_Priority The relative importance or ranking of the procedure compared to others performed. This generally applies to procedures performed during an operation.

Was_Primary_Procedure Whether the procedure was considered the primary procedure of an operation. This field overlaps with “Procedure_Code_Priority” (e.g. IF Procedure_Code_Priority = 1 THEN Was_Primary_Procedure = TRUE). However,

2 not all systems assign a priority, so this can be used to make the distinction between primary and secondary procedures.

Total_Anesthesia_Units The total number of units charged by the anesthesiology provider. This only applies to time-based, anesthesia procedure codes.

Tips & Recommendations

The most important fields in this module to fill in are Global_Patient_ID or Patient_ID, Date_of_Service_Start, and Procedure_Code. This can be considered the absolute minimum in most cases, but other columns should be filled in where possible.

It is usually a good idea to use your billing system as a source of data, even if it is available elsewhere. Given that the codes in the billing system are financially critical, they are almost guaranteed to be the most accurate.

3 Procedure Modifiers

This module is used to import billing modifiers on procedure codes. Common billing modifiers are small two character codes such as “QS” or “GC”.

Target Summary

Column Name Data Type Description Global_Patient_ID string Cross-system patient identifier, typically MRN Patient_ID string Local patient identifier Visit_ID string The visit or stay during which the procedure occurred Operation_ID string The operation during which the procedure occurred Invoice_Number string The invoice the procedure was charged on Procedure_Code_ID string A unique identifier for the specific charge Procedure_Source_Type string Professional fee vs. hospital discharge Date_of_Service_Start datetime The time the procedure occurred or started Date_of_Service_End datetime The time the procedure ended Date_of_Admission datetime The time when the patient was admitted Date_of_Discharge datetime The time when the patient was discharged Procedure_Code string The given procedure code (e.g. 00222) Procedure_Code_Lexicon string The dictionary the procedure belongs to (e.g. CPT) Modifier_Code_Lexicon string The dictionary the modifier belongs to Modifier_Code string The given modifier code (e.g. QS)

Examples

Procedure Modifier Examples

Column Descriptions Global_Patient_ID An identifier used to identify the patient across the institution. Typically this is a medical record number.

Patient_ID An identifier from the source system that uniquely identifies the patient the procedure was performed on. Patient_ID can be the same as Global_Patient_ID if the source system uses the same identifier (e.g. billing systems commonly use MRN to identify patients).

Visit_ID An identifier that links the procedure code to a patient visit. If your system does not support the “visit” concept or this link is not explicit in the data, this can be left blank.

4 Operation_ID An identifier that links the procedure code to a specific operation. This only applies to procedures that were performed during an operation. This field should be filled only when an EXPLICIT link is in the source system. See the “Do Not Create Data Links” section for additional details.

Invoice_Number The invoice identifier that the procedure code appears on. This obviously only applies to data from billing systems.

Date_of_Service_Start The date and time when the procedure was performed. This can also represent when the procedure was started.

Procedure_Code The code representing the procedure performed.

Procedure_Lexicon The dictionary from which the procedure code was taken. This field will be mapped to available MPOG concepts such as “CPT”, “ICD-9”, or “ICD-10”.

Modifier_Code_Lexicon The dictionary from which the modifier code was taken. This field will be mapped to available MPOG concepts such as “CPT” or “HCPCS”.

Modifier_Code The actual code for the modifier. Examples include “QS” or “GC”.

Tips & Recommendations

Procedure modifiers are not used that often in research requests and therefore this module can be considered low-priority. Of course, it should be implemented whenever possible.

5 Diagnoses

Target Summary

Column Name Data Type Description Global_Patient_ID string Cross-system patient identifier, typically MRN Patient_ID string Local patient identifier Visit_ID string The visit or stay during which the procedure occurred Operation_ID string The operation during which the procedure occurred Invoice_Number string The invoice the procedure was charged on Procedure_Code_ID string A unique identifier for an associated procedure Procedure_Code string An associated procedure for the diagnosis Diagnosis_Code_ID string A unique identifier for the specific charge Diagnosis_Source_Type string Professional fee vs. hospital discharge Date_of_Service_Start datetime The time the procedure occurred or started Date_of_Service_End datetime The time the procedure ended Date_of_Admission datetime The time when the patient was admitted Date_of_Discharge datetime The time when the patient was discharged Date_of_Diagnosis_Start datetime The time when the diagnosis began Date_of_Diagnosis_End datetime The time when the diagnosis ended Diagnosis_Code string The given diagnosis code (e.g. 275.1) Diagnosis_Lexicon string The dictionary the code belongs to (e.g. ICD-9) Diagnosis_Code_Priority integer The relative importance/rank of the procedure Was_Primary_Diagnosis boolean True = primary, False = not primary, null = unknown Present_On_Admission boolean Whether the diagnosis was present on admission

Examples

Diagnosis Examples

Column Descriptions Global_Patient_ID An identifier used to identify the patient across the institution’s systems. Typically this is a medical record number.

Visit_ID

6 An identifier that links the diagnosis code to a patient visit. If your system does not support the “visit” concept or this link is not explicit in the data, this can be left blank.

Operation_ID An identifier that links the diagnosis code to a specific operation. This only applies to procedures that were performed during an operation. This field should be filled only when an EXPLICIT link is in the source system. See the “Do Not Create Data Links” section for additional details.

Invoice_Number The invoice identifier that the diagnosis code appears on. This obviously only applies to data from billing systems.

Procedure_Code_ID An identifier that uniquely identifies a related procedure code in the source system. Procedure codes should be unique across patient, time, and procedure code. If no such identifier exists leave this field blank.

Procedure_Code A procedure code related to this diagnosis. Where not available or applicable, leave this blank. When used, this is typically a CPT or ICD procedure code.

Diagnosis_Code_ID An identifier that uniquely identifies the diagnosis code in the source system. Diagnosis codes should be unique across patient, time, and diagnosis code. If no such identifier exists leave this field blank.

Diagnosis_Source_Type Describes where the data originated. This field will be mapped to several MPOG concepts that include “Anesthesia Pro-Fee Billing”, “Surgery Pro-Fee Billing”, and “Hospital Discharge Billing”.

Date_of_Service_Start The date and time when the procedure was performed. This can also represent when the procedure was started.

Date_of_Admission The date the patient was admitted to the institution.

Date_of_Discharge The date the patient was discharged from the institution

Date_of_Diagnosis_Start The time when the given diagnosis was made or when the condition started.

Date_of_Diagnosis_End The time when the given diagnosis or condition ended.

Diagnosis_Code The code representing the given diagnosis.

Diagnosis_Lexicon The dictionary the “Diagnosis_Code” belongs to. Typically this is either “ICD-9” or “ICD-10”.

7 Diagnosis_Code_Priority The relative importance or ranking of the procedure compared to others performed. This generally applies to procedures performed during an operation. If this does not

Was_Primary_Diagnosis Whether the diagnosis was considered the primary diagnosis of an operation. This field overlaps with “Diagnosis_Code_Priority” (e.g. IF Diagnosis _Code_Priority = 1 THEN Was_Primary_ Diagnosis = TRUE). However, not all systems assign a priority, so this can be used to make the distinction between primary and secondary diagnoses.

Present_On_Admission Whether the diagnosis was present on admission. This is generally only found in data from hospital discharge billing.