How to Handle Implementation when Patient Records are Missing Procedural Codes (CPT-4 Codes and G-Codes)
folder_openSurvey Specifications and Guidelinescalendar_todayPosted July 7, 2016

The Centers for Medicare & Medicaid Services (CMS) and the OAS CAHPS Survey Coordination Team acknowledge that, occasionally, procedural codes (CPT-4 and G-codes) may be missing for some patient records included in the monthly patient data file that the survey vendor receives from a facility. When this happens, survey vendors are required to encourage their client to provide a completed monthly patient data file by the vendor’s set deadline, which will allow them to initiate data collection within the acceptable window of time. However, there may be instances when the facility cannot provide procedural codes for all of the patient records by the vendor’s sampling deadline. When this happens, vendors should work with the facility to determine whether the procedural codes can be provided at a later date, or not at all. After making this determination, the vendor should follow the guidance below that explains what steps should be taken if data collection is delayed, how to sample files with missing procedural codes, and how to categorize the surgery in the XML file(s).

Guidelines for when procedural codes can be provided at a later date

1. The vendor should request that an updated monthly patient data file, containing the procedural code data, be submitted before the 26th day of the month following the sample month. If the updated monthly patient data file is received by the 26th day of the month following the sample month, the vendor should follow the guidance provided in either bullet a or b below.
1. If the vendor has been approved to conduct continuous sampling for the affected facility, the vendor may conduct an additional round of sampling on the updated records. If data collection for the newly sampled cases is initiated between 21 and 26 days after the end of the sample month, the vendor is required to submit a Discrepancy Notification Report (DNR).
2. If the vendor is conducting monthly sampling for the affected facility, the vendor should wait to conduct sampling activities until they have received the requested information on all patients included in the monthly patient data file. If data collection is initiated between 21 and 26 days after the end of the sample month, the vendor is required to submit a DNR.


2. If the updated monthly patient data file is submitted to the vendor after the 26th day of the month following the sample month and additional eligible cases are identified, the vendor should submit a Late Start Request to the OAS CAHPS Survey Coordination Team, regardless of whether the facility is conducting continuous sampling or monthly sampling. If the request is approved, the vendor should proceed with data collection activities. Note that monthly sampling cannot be done on a partial file so if updates are expected for some cases, the vendor must wait to select the sample

1. If the facility cannot provide an update to records with missing procedural codes, the vendor should do the following:
1. Work with the affected facility to identify an alternative method of determining eligibility for these cases and submit the proposed alternative method in an Exceptions Request Form (ERF). If the proposed alternative method is approved, then follow the protocol in 1. or 2. above to initiate data collection.
2. Work with the facility to identify how the cases should be coded for the "Surgical Category" variable, which must be included in the XML file.
3. Once sampling is complete, the vendor will also be required to submit a DNR to report the number of cases that were fielded using the alternative method to determine eligibility and how each case’s “Surgical Category” was determined.


2. If the facility cannot provide an update to records with missing procedural codes, and the facility is unable to determine an alternate method of determining eligibility, the vendor should do the following:
1. Assume that the patient records with missing procedural codes are eligible if they meet all of the other eligibility criteria, and include them in the sample frame. Follow the protocols described in 1. or 2. above to initiate data collection.
2. Work with the affected facility to determine how the cases should be coded for the "Surgical Category" variable, which must be included in the XML file. For example, if the facility can determine that the cases with missing procedural codes were pulled from the Orthopedics department, then assign the cases to “surgical category 2 (orthopedic).” In this example, if the facility cannot identify a department or another method that would determine how the cases should be classified, assign the cases to “surgical category 4 (other).”
3. Once sampling is complete, submit a DNR reporting that sampled cases with missing procedural codes were fielded for a given sample month. Be sure to include the number of affected cases and the reason that the procedural codes are missing. Also include a description of the method used to determine each of the case’s “Surgical Category” for the XML file and for how many cases.

Please note that the above guidance supersedes the previous protocol that indicated that sampling cases with missing procedural codes was not permitted. The clarification provided in this announcement will be included in the next version of the Protocols and Guidelines Manual.

Please contact the OAS CAHPS Survey Coordination Team via e-mail at oascahps@rti.org or call toll-free (866) 590-7468 if you have any questions on how to handle cases with missing procedural codes.