KHDS
Kansas Health Data System
ABSTRACT
ENTRY
MANUAL
Winter 2014
KHDS STAFF
Deanna Karle,
Manager
Todd Colglazier,
Senior Field
Representative
Phone:
785 291-8702
FAX:
785 290-0722
E-mail:
[email protected]
Phone:
785 291-8830
FAX:
785 290-0722
E-mail:
[email protected]
Phone:
785 291-7658
Kelly Rippel,
Systems
Specialist
FAX:
Luke Hillin,
Abstract
Technician
Phone:
785 291-8891
FAX:
785 290-0722
E-mail:
[email protected]
Phone:
785 291-7291
FAX:
785 290-0722
E-mail:
[email protected]
Mary Schneider,
Administrative
Assistant
E-mail:
785 290-0722
[email protected]
KHDS E-mail: [email protected]
** Please Note **
The applications listed on the following pages
are the only applications available to you.
Please do not attempt to access any other application.
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Your terminal number is located in the lower right hand corner of the screen.
To access PIMS for the Kansas Health Data System, place your cursor beside PIMS
and press [ENTER]. Continue to follow instructions on the next page.
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1. Enter USER ID (7 characters) and press [TAB] key. (50XXXX0)
2. Enter Password in the PASSWORD field (key in your current password).
3. Press [ENTER].
NOTE: The NEW PASSWORD field is used only to change your password. This can
be changed at any time; however, you will be required to change your password every
90 days.
If you do not know or have forgotten your password, are suspended, or locked out of
the paperless system, please contact KHDS staff using one of the numbers published in
the front of this document.
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Changing Your Password
When changing your password, you must notify ALL USERS in your office of the new
password you selected. To change your password you must follow these steps EXACTLY:
1. Key in your current password then press the [TAB] key.
2. Key the new password in the NEW PASSWORD field.
3. Press the [END] key (this will clear the rest of the field from previous data).
4. Press [ENTER].
NOTE: The password you select and enter must meet the criteria on the following page.
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Guidelines For Creating A New Password
When your password expires, you will need to follow the guidelines below for creating
passwords.
The password must be eight (8) characters long and must contain:
1.
at least one (1) letter (a-z or A-Z),
2.
at least one (1) number (0-9), and
3.
at least one of three (3) “national” characters (@, #, $) somewhere in
positions 2-7.
4.
no repeating characters ie; dd or 22
5.
no repeats of the last eight passwords used
6.
it cannot appear on the restricted pass word list.
NOTE: A list of restricted passwords has been established. Some of the restrictions
are names of the month and anything that begins with the word NEW. Profanities are
also restricted. Please keep in mind these are only a few of the restrictions. If you received the error message RESTRICTED PASSWORD please select a new one.
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Last Used Message Information
This message will be displayed for each sign on. The message informs you of the time
of day and date your User ID was last used. The last used message will be similar to
that shown above.
Password Error Messages
When your password has expired or there is a problem with the new password you
have entered, a message will be displayed on the IMS/TM SIGN ON screen.
Examples of the messages you may receive follow.
TSS956E
PASSWORD HAS EXPIRED—
NEW PASSWORD MISSING
TSS957E
NEW PASSWORD (CHANGE) INVALID—
YOU CANNOT REPEAT CHARACTERS
TSS7102E PASSWORD MISSING
TSS7101E
PASSWORD INCORRECT
TSS7101E
PASSWORD VIOLATION THRESHOLD EXCEEDED
TSS7141E
USE OF ACCESSOR ID SUSPENDED
TSS7111E
NESS PASSWORD (CHANGE) INVALID–
CANNOT BE CHANGED YET
The message will be self-explanatory and you must comply with the instructions provided. If you have any questions or doubts, contact a member of the KHDS staff.
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On this screen type:
1. /FOR PAMAINMU (for Institutional business).
2. Press [ENTER].
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Press [F3] in the upper row of your standard keyboard to enter the KHDS
ABSTRACT TRANSACTION MENU. The following screen will appear, enter the PF
key for desired transaction.
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By selecting [F2] on the upper row of your standard keyboard (check to see your Flock key is engaged), you will enter into the KHDS ABSTRACT ENTRY SCREEN.
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The ABSTRACT ENTRY SCREEN will appear like this. On the following pages you
will find a step by step explanation of the screen fields and what is expected when
completing this form online.
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Medical Record Number, Required.
Field length is 30 alpha numeric characters long. KHDS will default leading zeros, you
may continue to provide your number in the same format you always have. Please note
if you wish to use a readmission indicator, there is no separate field for the indicator.
Please use an R in the first position of the 30 digit long field if you wish to track
readmissions.
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Patient Account Number, Required.
Required field if primary pay is Blue Cross Blue Shield of Kansas (BL), recommended
for other payers. Default to Medical Record Number if necessary, KHDS will default
leading zeros. Field length is 15 alpha numeric positions long.
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Patient Name, Required.
L = Last Name
F = First Name
Names are required for Blue Cross Blue Shield of Kansas abstracts. If primary pay
status is BL, names are required. Default this to LLLL only if not known for last name,
default to FFFF only if not known for first name. An error will result if valid names for
twin babies are not entered. Do not enter middle name or initial on BCBSKS twin
babies.
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Patient Gender, Required.
Acceptable values are:
M
F
U
=
=
=
Male
Female
Unknown
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Patient Race, Required.
Acceptable values are:
A = Asian or Pacific Islander
B = Black
C = Caucasian
D = Subcontinent Asian American
E = Other Race or Ethnicity
F = Asian Pacific American
G = Native American
H = Hispanic
I = American Indian or Alaskan Native
J = Native Hawaiian
P = Pacific Islander
N = Black (Non-Hispanic)
O = White (Non-Hispanic)
Z = Mutually Defined
1 = White
2 = Black
3 = American Indian/Alaska Native
4 = Asian
5 = Native Hawaiian / Pacific Islander
6 = Other
7 = Not Provided
8 = Not Applicable
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Date of Birth, Required.
Valid Calendar Date, format is MMDDCCYY. Example of October 15, 1951 would be
entered at 10151951. This field may be forced if an error is encountered on a Blue Cross
and Blue Shield of Kansas patient for eligibility. Please verify identification number and
birth date of patient prior to forcing. This would occur if the date of birth recorded in
BCBSKS eligibility did not match the date of birth on the abstract.
Ethnicity, recommended, acceptable values are:
1 = Hispanic
2 = Non-Hispanic
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Admission Fields Including Date, Hour, Accommodation, Class, Required.
Admission Date – Valid Date of Admission, verify that the date is on or after the date
of birth and on or less than the discharge date. MMDDYY format. First identify the
month, January through December are numbered 01 through 12. Use a lead zero for
January through September. Values are 01-09, 10, 11, 12. Days of the month are designated with a leading zero for days up through the 9th. The year is recorded as XX. Example, March 9th 2008 would be recorded as 030908.
Admission Hour – 00-23, verify value is within data range. Round minutes down to
the hour, default to 00 if unknown.
The admission hour is set up so that international time is used. Code midnight to 12:59
pm as 00 through 12 and 1:00 pm to 11:59 pm as 13 through 23. In coding hour of admission, disregard minutes.
Example: The admission hour for any patient admitted from 8:00 am to 8:59 am is
designated as 08. The time for any admission from 8:00 pm to 8:59 pm is designated
as 20.
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Accommodation Code - Values are as follows, verify the code is one of the values in
the following data range. If equal to 5 (special unit) then special unit 1 and special unit
1 days needs to be populated with valid code.
1 = Private of Single Room
3 = Multiple Occupancy Room
5 = Special Unit
7 = Birthing Room/Labor Room
9 = Other
2 = Semi-Private Room
4 = Nursery
6 = Hall
8 = Other
Enter the appropriate code to indicate the accommodation occupied in the hospital at
the time of admission. Since the type of accommodation may have changed during
hospitalization, exercise care in completing this. The face sheet of the medical record
normally contains the type of accommodations assigned on admission, which may not
be the accommodation upon discharge.
Code 1 = Single (Private), assigned to those patients who have occupied a single
bed accommodation.
Code 2 = Semiprivate, assigned to those patients who have occupied an
accommodation containing two beds.
Code 3 = Multiple, assigned to those patients who have occupied an
accommodation containing three or more beds.
Code 4 = Nursery, to be used for newborns.
Code 5 = Special Unit, used only for those patients who have either been directly
admitted or discharged from a special unit or who have expired in the special
unit.
Code 6 = Hall, assigned to those patients who have been placed in the hall.
Code 7 = Birthing/Labor/Delivery Room, assigned to those patients who have
occupied the labor room.
Code 8, 9 = Code 8 or 9 for any accommodation that is unique to your hospital.
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Admission Class – Verify the field is 1, 2, 3, 4, or 5. Values are as follows:
Code 1 = Emergency, true emergency admissions apply to medical conditions
or acute trauma such that life limb, or the body function of the patient depends
on the immediacy of medical treatment. In an emergency admission, the condition requires immediate medical attention and any time delay would be
harmful to the patient. The patient does not have to be admitted via the
emergency room to be considered an emergency admission.
Code 2 = Urgent, urgent admissions involve medical conditions or acute
trauma such that medical attention, while not immediately essential, should be
provided very early in order to prevent possible loss or impairment of life, limb,
or body function. This group includes those cases where very early medical
evaluation or treatment is necessary because the patient has either serious disease or injury or symptoms of such disease or injury. True emergency does
not exist.
Code 3 = Elective, elective admissions refer to those patients designated as
scheduled or routine admissions. This group includes those cases where there
is no urgency for immediate or very early medical evaluation or treatment because the possibility of serious consequences resulting from lack of medical attention is small.
Code 4 = Newborn, newborn admissions refer to all infants born in the hospital.
Code 5 = Obstetrics, Pregnancy related admissions / delivered or undelivered.
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Discharge Fields Including Date, Hour, Accommodation, Patient Status
upon Discharge addressed later in document,
Required.
Discharge Date – Valid Date of Discharge, verify that the date is on or after the
date of birth and on or less than the discharge date. MMDDYY format. First identify the month, January through December are numbered 01 through 12. Use a lead
zero for January through September. Values are 01-09, 10, 11, 12. Days of the month
are designated with a leading zero for days up through the 9th. The year is recorded
as XX. Example, March 9th 2008 would be recorded as 030908.
Discharge Hour – 00-23, verify value is within data range. Round minutes down
to the hour, default to 00 if unknown.
The discharge hour is set up so that international time is used. Code midnight to
12:59 pm as 00 through 12 and 1:00 pm to 11:59 pm as 13 through 23. In coding hour
of discharge, disregard minutes.
Example: The admission hour for any patient admitted from 8:00 am to 8:59 am is
designated as 08. The time for any admission from 8:00 pm to 8:59 pm is designated as 20.
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Accommodation Code - Values are as follows, verify the code is one of the values in
the following data range. If equal to 5 (special unit) then special unit 1 and special unit
1 days needs to be populated with valid code.
1 = Private of Single Room
2 = Semi-Private Room
3 = Multiple Occupancy Room
5 = Special Unit
7 = Birthing Room/Labor Room
9 = Other
4 = Nursery
6 = Hall
8 = Other
Enter the appropriate code to indicate the accommodation occupied in the hospital at
the time of admission. Since the type of accommodation may have changed during
hospitalization, exercise care in completing this. The face sheet of the medical record
normally contains the type of accommodations assigned on admission, which may not
be the accommodation upon discharge.
Code 1 = Single (Private), assigned to those patients who have occupied a single
bed accommodation.
Code 2 = Semiprivate, assigned to those patients who have occupied an
accommodation containing two beds.
Code 3 = Multiple, assigned to those patients who have occupied an
accommodation containing three or more beds.
Code 4 = Nursery, to be used for newborns.
Code 5 = Special Unit, used only for those patients who have either been directly
admitted or discharged from a special unit or who have expired in the special
unit.
Code 6 = Hall, assigned to those patients who have been placed in the hall.
Code 7 = Birthing/Labor/Delivery Room, assigned to those patients who have
occupied the labor room.
Code 8, 9 = Code 8 or 9 for any accommodation that is unique to your hospital.
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Insurance Identification Number Required on BCBSKS, Recommended for other payers.
The Blue Cross Blue Shield of Kansas identification number is required if the Primary
Pay Status is BL. Must be a valid Blue Cross prefix and Identification number including the 'R' for federal BCBSKS. Leading prefixes are required if present on the ID card.
Valid prefix example would be XSB. If the prefix as entered is in error, check for valid
Kansas Insured, may be out of state Blue Cross. A valid prefix list may be obtained on
our website http://www.bcbsks.com/khds/.
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Total Charge, Recommended.
Value is charge in dollars – no cents; round to nearest whole dollar. Field values
are 0-9999999 – if greater than 9999999 default to 9999999.
Objectives for recording total hospital charges for the period of hospitalization are:
1. For related charges for hospitalization to diagnostic and other individual patient
information, and
2. To provide data for efficient and economical hospital management.
Total charges are listed without regard to the source of payment and are rounded to
the nearest dollar. The business office should be consulted relative to this data.
Example: The total charges for patient 54326 were $2,214.52 and would be entered as 0002215. The operator must input the leading zeros.
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Referral Source Code, Required. Referral Source ID, Optional.
Referral Source Code - Verify code is within data range as follows:
D = Transfer Within Hospital
NB = Newborn
11 = Physician’s Office
21 = Inpatient Hospital
23 = Emergency Room – Hospital
25 = Birthing Center
31 = Skilled Nursing Facility
33 = Custodial Care Facility
51 = Psychiatric Mental Health
Facility
61 = Comprehensive Inpatient
Rehabilitation Facility
OP = Outpatient Department at same
hospital
12 = Home Health
22 = Other Outpatient Hospital
24 = Ambulatory Surgery Center
26 = Military Treatment Facility
32 = Nursing Facility
34 = Hospice
54 = Intermediate Care Facility for
Mentally Retarded
99 = Other Unlisted Facility
Referral Source ID - To records any four character, A-Z, 0-9, facility ID identifying
referring facility. This item is used to designate the facility transferring patient to
hospital. Examples: nursing homes, etc.
Note: KHDS is no longer updating the list. Each facility may assign their own
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Transfer Destination Code Facility Type, Required. Transfer Destination
ID, Optional.
Transfer Destination Code Facility Type – Required if UB04 discharge status is equal
to a transfer, verify code is within data range as follows:
12 = Home Health
26 = Military Treatment Facility
32 = Nursing Facility
34 = Hospice
51 = Psychiatric Mental Health
Facility
61 = Comprehensive Inpatient
Rehabilitation Facility
21 = Inpatient Hospital
31 = Skilled Nursing Facility
33 = Custodial Care Facility
35 = Adult Living Care Facility
54 = Intermediate Care Facility for
Mentally Retarded
99 = Other Unlisted Facility
Transfer Destination ID – Optional to record any four characters, A-Z, 0-9, facility
transferred to.
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Primary Payment Status, Required. Secondary Payment Status, Optional.
Primary Payment Status – Verify code is within data range of the validation table that
follows. If 'BL' (Blue Cross Blue Shield of Kansas), then a valid prefix and insurance ID
are required.
BL
=
Blue Cross and
NK
=
Non-Kansas Blue Cross
Blue Shield of KS
and Blue Shield
CH
=
Champus
CI
=
Commercial Insurance
FR
=
Free
GV
=
Other Government Program
HM
=
HMO
HW =
Healthwave
MC
=
Medicaid
MA =
Medicare Part A
09
=
Self Pay
12
=
Preferred Provider
OT
=
Other
WC =
Workman’s Compensation
Secondary Payment Status – Verify the code is within data range of the validation table
above (same values as Primary Pay Status).
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Service Code Type of Patient, Required.
Verify the code is valid for your facility, verify age specific (pediatric) and gender
specific service codes. See following table for values. Specific hospital choices must be
related to KHDS for edit specifications.
(continued next page)
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(Service Codes continued)
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Hemoglobin Low, Required. Hemoglobin High, Required.
Hgb Low – Required if DRG is 0736, 0737, 0738, 0739, 0740, 0741, 0742, 0743, 0765,
0766 and payment status is 'BL.' Decimals indicate tenths. Lowest hemoglobin level
during hospitalization (include pre-op lab).
Hgb Drop - Required if DRG is 0736, 0737, 0738, 0739, 0740, 0741, 0742, 0743, 0765,
0766 and payment status is 'BL.' Decimals indicate tenths. Drop from highest
hemoglobin during hospitalization (include pre-op lab).
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Patient Discharge Status –
01 = DIS to home or self care (routine discharge)
02 = DIS to another short-term gen. hosp. for inpatient care
03 = DIS/transferred to skilled nursing facility
04 = DIS/transferred to intermediate care facility
05 = DIS/transferred to another type of institution
06 = DIS to a home under care of organized home health service organization
07 = Left against medical advice or discontinued care
20 = Expired
21 = DIS/Trans to Court/ Law Enforcement
41 = Expired In Hospital (Hospice)
43 = DIS/Trans To Federal Hosp.
50 = Hospice – home
51 = Hospice – medical facility
61 = DIS/transferred within this institution to a hospital-based Medicare
approved swing bed
62 = DIS/transferred to another rehabilitation facility including
rehabilitation distinct part units of a hospital
63 = DIS/transferred to a long term care hospital
64 = DIS To Cert Medicaid NF
65 = DIS/Trans To Psych Facility
66 = DIS/Trans To CAH
70 = DIS/Trans To Other
81 = Routine Home With P.A.C.H.I.R.
82 = Trans To HOSP With P.A.C.H.I.R.
83 = Trans To SNF With P.A.C.H.I.R.
84 = Trans to CUST With P.A.C.H.I.R.
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Patient Discharge Status – continued
85 = Trans To Cancer With P.A.C.H.I.R.
86 = Trans To Home Health With P.A.C.H.I.R.
87 = Trans To Court With P.A.C.H.I.R.
88 = Trans To Federal With P.A.C.H.I.R.
89 = Trans To Swing Bed With P.A.C.H.I.R.
90 = Trans To Rehab With P.A.C.H.I.R.
91 = Trans To Long Term Care Home With P.A.C.H.I.R.
92 = Trans To Nursing With P.A.C.H.I.R.
93 = Trans To Psychiatric With P.A.C.H.I.R.
94 = Trans To CAH With P.A.C.H.I.R.
95 = Trans To Other With P.A.C.H.I.R.
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Zip Code, Required.
Five-digit zip code as provided by U.S. Post Office. The four-digit suffix can be added
as supplied. The four-digit number is not required.
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Attending Physician, Required.
Other Physician, Recommended if applicable.
Attending Physician – Any ten-digit NPI number previously communicated to KHDS.
All physician numbers need to be reported to KHDS staff prior to keying an abstract
with those physicians.
Other Physician – Any ten-digit NPI number previously communicated to KHDS –
physician other than attending, surgeon, or consulting. Example: Assistant surgeon,
etc.
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Consulting Physician 1, 2, and 3, recommended.
Valid ten-digit NPI number previously communicated to KHDS, may not be the same
number as attending or other physician.
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Coder ID, Optional data element.
This hospital-assigned, three digit identifier allows for tracking and auditing of abstract
record entry.
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Special Unit and Days, Required if Applicable.
Verify that the code is within data range of validation table that follows and that either
the accommodations on admission or discharge is equal to a '5' for special units. For
Days, values are 00 – 99, verify special unit is completed. Number of days of combined
special unit days cannot exceed total length of stay (discharge date minus admit date).
There may be an occasion where the patient was in a special unit but not at admission
or at discharge. Valid codes for units follow:
H = Hospice
6 = SHORT PROCEDURE UNIT
0, 8, 9 = Other
7 = SELF CARE
1 = ICU
2 = CCU
3 = BURN
4 = ISOLATION
5 = PSYCH
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Admitting Diagnosis, Required.
Verify valid ICD-9-CM / ICD-10-CM (on or after 10/01/2014) diagnosis code. Decimals are implied and should not be entered. There are seven positions, begin in the
first position and tab to next field when diagnosis code is completed.
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DRG, Calculated Field.
Upon completion of abstract a DRG will be assigned if the abstract is error free. Press
enter after completion and abstract will return with calculated fields complete.
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Diagnosis Codes, Required through at least the first code.
POA Codes, Required if Diagnosis Code is present,
ICD Version Code—2 digits(9, 10,11)
Diagnosis Code - Verify valid ICD-9-CM / ICD-10-CM diagnosis codes, field allows up to 25
diagnosis codes to be entered. Decimals are implied and should not be entered. There are
seven positions in each diagnosis code, begin in the first position and tab to the POA field
when the diagnosis code is completed.
POA Code – Every diagnosis code submitted should have an accompanying, valid Present on
Admission indicator code. Valid codes are as follows:
Y
=
Present at the time of inpatient admission
N
=
Not present at the time of inpatient admission
U
=
Documentation is insufficient to determine if condition is present
on admission
W
=
Provider is unable to clinically determine whether condition was
present on admission or not
1
=
Unreported/Not Used (Exempt from POA reporting)
Note: A blank will also be accepted with POA exempt diagnosis codes,
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Procedure Codes, Date and Surgeon, Required if there are procedures.
Verify valid ICD-9-CM / ICD-10-CM procedure code. Decimals are implied. There are
seven positions for each procedure code, begin in the first position and tab to next field
when procedure code is completed. Blank if not applicable. Associated procedure
date and surgeon must also be populated. Dates are MMDDYY. A valid calendar date, equal to or prior to discharge date, is required if there is a procedure. Procedure dates may be 1 day prior to admit date if referral source = OP (outpatient department) or 3 days prior to admit if referral source = OP and primary payor status = MA
(Medicare). Verify all dates have associated procedure codes and surgeon NPI numbers. Verify valid surgeon number has previously been communicated to KHDS. Associated procedure code and procedure date must also be completed. There is space for
25 procedure codes/dates/surgeons.
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External Cause of Injury (ECI) Data Element 1 through 12,Required if applicable.
Required if applicable DRG and Primary Pay Status is 'BL.' See attachment D for specific DRGs
and values.
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Severity & Intensity Data Element 1 through 36, Required if applicable.
Required if applicable DRG and Primary Pay Status is 'BL.' See attachment D for specific DRGs and values.
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Definitions of Terms in Manual
Cursor
Highlighted indicator shows you where you are on the display.
Cursor Select
Place the highlighted indictor at a particular field.
Menu
A list of the various transactions available to you within the
Electronic Media Services.
Entry
The input of information into the PIMS.
Inquiry
Transaction whereby abstractors may obtain information as to
abstract status, daily abstract totals, physician DRGs, etc.
Field
A set of character positions next to each other on the screen.
Screen
Display on terminal.
Truncation
If more characters or numbers are entered into a field than there
are spaces, the information will be truncated or cut off to the
number of available spaces.
Log Off
Signing off PIMS.
Hours of
Operation
The KHDS system will be available five days a week and four nights
a week except for those specific holidays observed by Blue Cross
and Blue Shield of Kansas. The schedule for system availability is:
Monday thru Friday
7:00 am to 5:30 pm
Monday thru Thursday nights 7:00 pm to 11:00 pm
Saturday
7:00 am to 11:30 am
Holidays
Blue Cross and Blue Shield of Kansas currently observe eight (8)
holidays that close the service center. On these eight days the
Paperless Network will not be available:
New Year’s Day
Thanksgiving Day
Memorial Day
Day After Thanksgiving
Independence Day
Christmas Day
Labor Day
Last working day before
Christmas
The Corporation’s policy concerning the two Christmas holidays
varies depending on the day the holiday falls on. KHDS will be
responsible for notifying you of the exact dates of the Christmas
holiday and of any changes or additions to the existing schedule.
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Transmittal/Release process (F10 Key)
1. Enter the month and year of the month of abstracts that you wish to release/transmit (MMYY
format).
2. Tab to the TRANSMITTAL TYPE field (skip over the 'TOTAL ABSTRACTS FOR MONTH’ field)
and key in a 'B'.
3. Hit ENTER.
4. Verify that the 'TOTAL ABSTRACTS FOR MONTH' is correct and verify the LOS is reasonable.
Only complete and forced abstracts can be transmitted. Any incomplete abstracts will need to be
completed before you can transmit.
5. Go back to the 'TOTAL ABSTRACTS FOR MONTH' field and key in the appropriate number.
6. Hit ENTER.
7. Screen print the transmittal/release verification if you would like.
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