2019 AQI NACOR DATA ELEMENT CONCEPTUAL DEFINITIONS Anesthesia Quality Institute Version 3.0 7/1/2019 2019 AQI NACOR DATA ELEMENT CONCEPTUAL DEFINITIONS Version 3.0 July 2019 This document clarifies data element conceptual definitions and intent. Synonyms, examples, exclusions and/or notes are included where appropriate and available. Clarifications to these will be made on an as-needed basis. Updates to the official conceptual definitions will be made on an annual basis. Comments or recommendations should be sent to [email protected]. This version includes the data elements in AQI NACOR Data Element Conceptual Definitions v2.0 and a set of comorbidity data elements released in December 2017. AQI NACOR Data Element Conceptual Definitions for Use During CY 2019 Ju2019 v3.0 TABLE OF CONTENTS MINIMUM DATA SET DATA ELEMENTS .................................................................................................................................... 10 ANESTHESIA START TIME ...................................................................................................................................................... 10 ANESTHESIA END (FINISH) TIME ............................................................................................................................................ 10 ANESTHESIA TYPE .................................................................................................................................................................. 10 ANESTHESIA PHYSICAL STATUS CLASSIFICATION .................................................................................................................. 12 CPT CODE – ANESTHESIA ....................................................................................................................................................... 15 CPT CODE – SURGICAL ........................................................................................................................................................... 15 DATE OF SERVICE ................................................................................................................................................................... 15 FACILITY ID ............................................................................................................................................................................. 15 ICD CODE ............................................................................................................................................................................... 15 PATIENT AGE ......................................................................................................................................................................... 16 PATIENT DATE OF BIRTH ........................................................................................................................................................ 16 PATIENT SEX .......................................................................................................................................................................... 16 PAYMENT METHOD ............................................................................................................................................................... 17 PROVIDER CREDENTIALS ....................................................................................................................................................... 17 PROVIDER ID .......................................................................................................................................................................... 22 PROVIDER NPI NUMBER ........................................................................................................................................................ 22 UNIQUE ANESTHESIA EPISODE OF CARE ID ........................................................................................................................... 22 ADMINISTRATIVE DATA ELEMENTS .......................................................................................................................................... 23 ADMISSION STATUS............................................................................................................................................................... 23 COVERAGE CODE ................................................................................................................................................................... 23 LOCATION .............................................................................................................................................................................. 26 PATIENT CHARACTERISTICS ................................................................................................................................................... 31 PROCEDURE STATUS.............................................................................................................................................................. 32 TIME ...................................................................................................................................................................................... 32 OUTCOME DATA ELEMENTS ..................................................................................................................................................... 34 OUTCOME.............................................................................................................................................................................. 34 ACIDEMIA .......................................................................................................................................................................... 34 ACUTE KIDNEY INJURY (AKI) .............................................................................................................................................. 34 ADVERSE DRUG REACTION (ADR) ..................................................................................................................................... 34 AIRWAY OBSTRUCTION ..................................................................................................................................................... 34 AIRWAY TRAUMA .............................................................................................................................................................. 35 AMNIOTIC FLUID EMBOLISM ............................................................................................................................................ 35 ANAPHYLAXIS .................................................................................................................................................................... 35 ARRHYTHMIA .................................................................................................................................................................... 35 Page 2 of 95 AQI NACOR Data Element Conceptual Definitions for Use During CY 2019 Ju2019 v3.0 ASPIRATION ....................................................................................................................................................................... 35 AWARENESS ...................................................................................................................................................................... 36 BRADYCARDIA ................................................................................................................................................................... 36 BURN INJURY ..................................................................................................................................................................... 36 CANNOT VENTILATE .......................................................................................................................................................... 36 CARDIAC ARREST ............................................................................................................................................................... 36 CASE CANCELLED BEFORE ANESTHESIA START TIME ........................................................................................................ 37 CASE CANCELLED BEFORE ANESTHESIA INDUCTION TIME ............................................................................................... 37 CASE CANCELLED AFTER ANESTHESIA INDUCTION TIME .................................................................................................. 37 CASE DELAY ....................................................................................................................................................................... 37 CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLABSI) ................................................................................... 38 CENTRAL LINE PLACEMENT INJURY................................................................................................................................... 38 CEREBROVASCULAR ACCIDENT ......................................................................................................................................... 38 COAGULOPATHY ............................................................................................................................................................... 38 COMA ...............................................................................................................................................................................