Procedures Tab Notes
NSW Users
The date and location are required for extended Day Procedural centres only. For sites that are same day, the episode date has been duplicated to Procedure date and location defaulted to 'This facility'.
If the Principal Procedure cannot be filled in, users can manually complete the episode by typing the date in the Completed field on the Notes tab.
A Principal Procedure maybe blank in the case of the patient was admitted but the procedure did not go ahead. The clinical coder is required to code why in the Diagnose tab.
Such reasons may include:
- Patient medically unfit for surgery (illness)
- Patient did not follow preadmission guidelines
- Surgeon not available for procedure
- Procedure centre not available for the procedure (equipment, staff, building)
Anaesthetics
Sedation type anaesthetics are required to be coded in the Secondary procedure area and contain the ASA type. The Anaesthetist is responsible for allocating the appropriate ASA type on the Anaesthetic clinic pathway record. This is typically recorded on the page as: ASA Code: 1 2 3 4
Anaesthetic items are five numeric characters followed by a dash and two digits (e.g. 92515-19). In this example the '1' represents the ASA code and the '9' indicates a day procedure centre (zeroes indicate large hospitals). If the form has no provision for this or the Anaesthetist has not coded then a '9' may be used to indicate 'Unknown' (e.g. 92515-99).
Local anaesthetics are not required to be listed. Please consult with a clinical coder for assistance in coding your Practice anaesthetics.
Diagnostic Related Group (DRG)
Certain health fund contracts include the requirement to use Diagnostic Related Group codes as part of the reporting. The Day Surgery module does not include this software.
There are several types of Grouper software available in Australia, with MedicalDirector choosing the 3M Group application - Day Surgery does not work with other types of Grouper software.
Not all Practices will need to purchase this application. Dependent on the procedural items used, it may be possible to manually code to their related DRG (i.e. use a summary of items and related DRG codes). Day Surgeries that are continuously operating with a number of theatres and/or specialty surgeons with a diverse range of procedures would benefit from installing this type of software to expedite workload.
The DRG version can be pre-set in the Add-Ins/Advanced/Settings area if the majority of contracts are based on a certain version. Use the drop down option to code under other versions.
To use, once the fields are completed, click the Group button. The DRG code will be automatically inserted. The View report will display the criteria for choosing a particular DRG.
This button transfers all procedure coding to another open/created episode that has been created within a 14-day window of the current episode.
The Completed button checks for any mandatory field that hasn't been completed and jumps to the field, ready for data entry. Once the field contains a valid entry, return to the Procedures tab and press it again. With no omissions, the program moves to the Notes tab.