6.02 ED PROCEDURE

PART OF THE ED PROCEDURE GROUP (6.01 - 6.08)

Definition

Service or intervention, not part of routine history or physical examination, that is designed for diagnosis or therapy.

Uses

Documentation of procedures performed during a patient’s ED visit is needed for clinical care, quality management, reimbursement, administration, and clinical and health services research.

Discussion

The predominant system for coding ED procedures in the United States is the Physicians’ Current Procedural Terminology (American Medical Association [AMA], 1997), abbreviated C4 in HL7, Version 2.3 (HL7, 1996). Several systems are available to code nursing interventions. Local codes or concise descriptions without codes can be used as required.

Data Type (and Field Length)

CE - coded element (200).

Repetition

Yes; the ED Procedure Group repeats when more than one procedure is performed.

Field Values

Component 1 is the procedure code.
Component 2 is the procedure descriptor.
Component 3 is the coding system identifier.
Components 4 - 6 can be used for an alternate code, descriptor, and coding system identifier.

Examples:

Component 1 = 93000
Component 2 = Electrocardiogram
Component 3 = C4
Component 1 = 31500
Component 2 = Endotracheal intubation
Component 3 = C4

Text data also can be entered without an accompanying code, as follows:

Component 1 = " "
Component 2 = Insertion of intravenous line

Data Standards or Guidelines

Physicians’ Current Procedural Terminology (AMA, 1997), Nursing Interventions Classification (McCloskey and Bulechek, 1995), The Omaha System: Applications for Community Health Nursing (Martin and Scheet, 1992), and The Classification of Home Health Care Nursing: Diagnoses and Interventions (Saba, 1992).

Other References

Health Level 7, Version 2.3 (HL7, 1996) and E1238-94 (ASTM, 1994).