Refer to Complex Case Study for the Remaining Questions:



SCQR Certification Exam Answer Key & Rationale*2018(Based on the January 2018 Manual) What is the minimum age of patient included in MSQC Program?A. 3B. 4C. 18The number of cycles per year in the MSQC program is 46.A. TrueB. FalseThe percentage of follow-up that must be achieved for MSQC?A. 75%B. 80%C. 90%The number of vacation cycles allowed per program year is 3.A. TrueB. False Excluding the optional hysterectomy and vascular cases, what is the maximum number of CORE cases that can be sampled each cycle?A. 25-35 [only 25 cases are CORE, the other 10 are optional hysterectomy & vascular cases]B. 25C. 35What is the number of attempts considered “due diligence” when obtaining 30-day follow-up?A. 2B. 3C. 4MISCELLANEOUS VARIABLESWhich CPT code represents a laparoscopic Appendectomy for a ruptured appendix?44950449554496044970 (RATIONALE: 44970 is the only laparoscopic appendectomy CPT available)You note the patient was taking Eliquis for chronic Afib prior to admission. The patient was discharged on POD 7 with order to resume Eliquis after their surgery. You would capture the Post-Discharge Extended VTE Prophylaxis variable as: Yes – Other – Eliquis (typed into text field)NoException – Therapeutic Anticoagulation AdministeredWhen abstracting family history of DVT/PE, “Unknown” would be the appropriate variable option to capture when a patient is adopted, stated family history is unknown, or when family history is not discussed in the medical record.True False (RATIONALE: The answer is False because the SCQR should answer “No” not “Unknown” if the family history is not discussed in the medical record. Only report Unknown if the patient is adopted or stated family history is unknown.)A patient was discharged the day of their surgery, never saw their surgeon again, and you sent them two letters and called three times, without any response. After researching obituaries online you find the patient expired on POD 45. How would you answer “Followed for 30 Days”? Yes [RATIONALE: Only if the patient expires before POD30, it is considered complete 30 day follow up, so this option is not correct]No, 0 days followed [RATIONALE: you only know what happened to the patient on the operative day (POD0), not the 30 days after surgery, so you have 0 days followed.] No, 45 days followed [RATIONALE: this is not correct because we only follow the patient through 30 days postop, and you do not know what happened to the patient after surgery so there is 0 days followed]A patient was scheduled for a partial colectomy with a colostomy for colon cancer. During the procedure, the surgeon performed extensive lysis of adhesions and repaired a serosal tear of the small bowel. Also, the femoral artery was nicked and the vascular surgeon was called in to repair the artery. Which procedure should be reported as the Principal Procedure? Partial colectomyLysis of adhesionsVascular procedureOrgan Repair (other than GYN, vascular, plastics)Colon/Small Bowel Resection A patient was scheduled for a partial colectomy with a colostomy for colon cancer. During the procedure, the surgeon performed extensive lysis of adhesions and repaired a serosal tear of the small bowel. Also, the femoral artery was nicked and the vascular surgeon was called in to repair the artery. Who performed the other procedure(S)? Primary SurgeonDifferent Surgical TeamBothA patient was scheduled for a partial colectomy with a colostomy for colon cancer. During the procedure, the surgeon performed extensive lysis of adhesions and repaired a serosal tear of the small bowel. Also, the femoral artery was nicked and the vascular surgeon was called in to repair the artery. Which other procedures performed should be reported? Select all answers that apply: Partial colectomyLysis of adhesionsVascular procedureOrgan Repair (other than GYN, vascular, plastics) Colon/Small Bowel Resection CASE INCLUSION When selecting cases for the sampling frame, a Laparoscopic Hiatal Hernia Repair was performed during a Sleeve Gastrectomy for bariatric surgery. Should the hiatal hernia repair be added to the sampling frame?No, because it was performed during a bariatric procedureNo, because hiatal hernia repair is not an eligible caseYes, because the hiatal hernia repair is a MSQC-included caseYes, because the sampling frame is short the number of required casesYou uploaded a Laparoscopic Cholecystectomy to your sampling frame, and the case was sampled. After reading the Op Report, you find that the case was aborted before the gallbladder was removed due to patient instability. The case was rescheduled and was eventually performed a month later on 11/2. Which of the following is the correct action?Abstract the sampled Laparoscopic Cholecystectomy case, but change the OR date to 11/2 Abstract the sampled Laparoscopic Cholecystectomy case as if the procedure was actually performedContact MSQC to make the case ineligibleSURGICAL PRIORITYPatient was admitted 1/31 for bowel obstruction with a “wait and watch” approach.? Progress notes up until day of OR (2/7) states “slow to progress” and then planning OR for 2/7.? Anesthesiologist documented it as 2E.? With this documentation, what should be captured as the surgical priority?ElectiveUrgentEmergent (RATIONALE: If anesthesia calls the case emergent, you can too. There’s a sentence that addresses this hidden in the Emergent definition: “…the surgeon and/or anesthesiologist documented the case as “Emergent” or ASA class of “3E” for example you may also record it as such.”)Patient was scheduled for elective Whipple d/t neoplasm on 1/29. On 1/4 had a biliary stent placed, on 1/27 was admitted to inpatient from the ED for elevated liver function tests found on preop lab draw. CT scan on 1/28 demonstrated bile duct dilation which is stable from prior biliary stent placement. Surgeon documented signs and symptoms likely secondary to a continued obstructive process from the mass resulting in a degree of chronic cholangitis. Patient remained in the hospital under observation until being sent to OR as planned on 1/29. Anesthesia recorded ASA Classification as 3. What should be captured as the surgical priority?Elective (RATIONALE: the patient did not have a deterioration in condition, was admitted to correct labs from a stable condition, and the surgery still took place at the scheduled time.)UrgentEmergentA patient is seen in the clinic for pre-op workup for chronic cholecystitis on May 4. A laparoscopic cholecystectomy is scheduled for May 11. On May 8, the patient goes to the ER for severe epigastric pain. It is determined that the patient has acute cholecystitis. The patient was admitted to the surgical floor for observation. Surgery was scheduled for late the next afternoon, on May 9. What would be selected for ‘surgical priority’? EmergentUrgent (RATIONALE: Urgent: Acute medical condition for which the patient needs intervention during admission and cannot be discharged home prior to intervention. Examples: acute cholecystitis, SBO not resolving after 3-4 days so the patient placed on schedule for planned exploration.ElectivePNEUMONIAMr. J. is a 68 yo male who was admitted on 4/9 and had a suture repair of perforated ulcer with open approach on 4/10. He has no documented pre-existing pulmonary history. On 4/11 respiratory crackles were noted. On 4/12 WBCs were 15.5 and moderate white secretions noted. Moderate tan secretions were documented on 4/13 with continuing crackles. An XRAY on 4/14 shows infiltrate. On 5/3 at 1500: VS 39.0, 121, 27, 127/70, 95% on room air and WBCs are 17.0. On 5/5: A CT scan showed consolidation, thick yellow sputum, a positive sputum culture and pneumonia diagnosis was documented. Dates4/74/84/94/104/114/124/134/144/154/164/175/25/35/45/55/65/75/8EVENTSAdmit, Surgery, Signs/Sx, CXR, CTADMORcracklesWBCTan secWBCRR>25sputum+CXR+CT7-day Infection Window (IW)xxxxxxxxxxxxxxxxxxDate of Occ (DOO)xxxxxxPresent on Adm (POA)xxxxxxRepeat Infection Timeframe (RIT) 4/11+14 days = 4/25 earliest eligible date to assign PNA againWhat are the date(s) of occurrence for this patient’s Pneumonia? Select all that apply4/11 4/145/2 (RATIONALE: not selected r/t pt does not have 2 included PNA signs/symptoms with +CT on 5/5)5/5 (RATIONALE: not selected r/t pt does not have 2 included PNA signs/symptoms with +CT on 5/5)Not enough information to document PneumoniaIf the patient meets the criteria for Pneumonia, is this preoperative or postoperative?PreoperativePostoperative (RATIONALE: the DOO is the day after OR)Both preop and postopNot enough information to document PneumoniaWhat date would the patient be eligible to assign another occurrence of pneumonia using the repeat infection timeframe? 4/25 (RATIONALE: RIT Day one is 4/11 + 14 days = 4/25. First eligible day to assign another PNA is 4/25)4/285/25/5Not enough information to document PneumoniaHow many imaging studies are required in order to meet criteria to assign pneumonia in this case?One (RATIONALE: The patient had no pulmonary/cardiac history)TwoNoneOther preoperative risk factor(s)that can be assigned based on this case study? Select all answers that apply.NoneSepsis due to pneumonia (RATIONALE: infection source: 2nd PNA meets MSQC criteria and PNA diagnosis on 5/3, had at least 2 signs/symptoms criteria on 5/3)Severe sepsis due to pneumoniaUnplanned intubationRefer to Complex Case Study for the Remaining Questions:Based on the Complex Case Study, how would you report the patient’s insurance? Commercial Insurance (non- HMO) BCBS MichiganHealth Maintenance Organization BCN MichiganHealth Maintenance Organization Medicaid HMO (RATIONALE: Blue Cross Complete of Michigan is listed in the definition under Medicaid HMO, it’s also in the insurances reference spreadsheet under the same, and also listed as a Medicaid managed care plan on the BCBS website, which is a Medicaid HMO). Government Insurance Medicaid (straight)What is the Hospital Admission Date?3/23/3 (RATIONALE: this is on page 1-face sheet, this is the date patient officially admitted to hospital)3/83/10What would you report as the Hospital Discharge Date/Time?4/17 @ 15:36POD30 @ 00:00 [RATIONALE: Per definition: If Still in Hospital >30 days is 'Yes', select the discharge date of POD 30 with a time of 00:00. Patient was d/c > 30 days after surgery]The Hospital Discharge Destination should be reported as:Discharged to home or self-careN/A - Pt. still in hospital >30 days [RATIONALE: The patient was still in hospital after POD 30]Disch/transf to skilled nursing facility (SNF)Disch/transf to long term care hospitalPREOPERATIVE RISK FACTORS:The ETOH > 2 Drinks per Day variable would be abstracted as:Yes (RATIONALE see p.1 provider notes)NoWould you assign Preop UTI? YesNo (RATIONALE: on 3/6 had <105 CFU in preop culture, so not eligible for UTI)COPD would be captured in this case.TrueFalse (RATIONALE: asthma is excluded from COPD)In terms of History of Smoking, how would you capture this?YesNo (RATIONALE: marijuana and e-cigarettes are excluded)If OR case # 2 was the sampled case, the Currently Requiring or On Dialysis within 2 weeks variable would be answered as:Yes (RATIONALE: OR case #2 was on 3/10, and the patient placed on dialysis on 3/8, it was within 2 weeks of the sampled surgery)NoHow would you abstract this patient’s Functional Health Status?IndependentPartially dependentTotally dependent (RATIONALE: the patient was intubated on 3/7, prior to any of the OR cases that could be sampled. On 3/8 before 1st surgery, RR was reported as being on vent)UnknownIf OR case # 2 was the sampled case, what is another preoperative risk factor that can be assigned?Sepsis Severe SepsisSeptic Shock (RATIONALE: OR #2= 3/10@1000, must be within 72 hours =3/7@1000Infection: 3/8@0800+cx & 3/7 suspected UTI/PNA/abdominal infx. Signs/Symptoms: 3/7@12:50 VS BP 85/49, HR>90, RR>20; 3/7@1300 labs Lactic>2, WBC>12=severe sepsis; 3/7 by 1500 (within 6 hrs of septic shock) sustained hypotension with vasopressors started to keep MAP>65. Septic Shock should be assigned since it is the highest level before surgery)AKISURGICAL VARIABLESLooking at OR cases #1, #2 and #3, during which cases were MSQC-included procedures performed that should be added to the Sampling Frame Template? Select all answers that apply. OR case #1 (cholecystectomy)OR case #2 (bowel left in discontinuity)OR case #3 (bowel resection with ostomy)(RATIONALE: All of the 3 surgical cases had eligible MSQC cases, and we do not exclude adding subsequent cases to the sampling frame, the Workstation does the exclusion for you after cases are uploaded.)If OR case #3 was the sampled case, please select the primary CPT code for this case (use CPT code reference of your choice):4412044125 (RATIONALE: small bowel resection with ileostomy)4414144310If OR case #3 was sampled, what is the wound classification for this procedure?CleanClean/ContaminatedContaminatedDirty/Infected (RATIONALE: This is the highest wound class that can be assigned r/t severe inflammation in Op report. This is listed in definition.)If OR case #3 was the sampled case how would Presence of Drains be captured? No drain in placeSubcutaneous drain(s) in placeIntracavity drain(s) Both subcutaneous and intracavity drains in placeDrains not captured for this CPT code. (RATIONALE: Due diligence in answering the question means first need to determine CPT code. CPT code 44125 does not require answering the drains variable.)If OR case #1 was sampled, how would you capture the events on the Discharge tab? Return to OR 3/10Return to OR 3/12Both a and bIn reviewing the anesthesia record, you find documentation that the patient was hypotensive and was given Levophed IVP. You would answer variable ‘Intraoperative use of vasopressor/inotropic medications’ as:YesNoIn reviewing the anesthesia record for the surgery performed on 3/12, you are not able to find any recorded EBL documented by the anesthesiologist but find the operative report, in which the surgeon documented “EBL=minimal”. You would capture_____as EBL in the workstation:0 mLMinimal25 mLNoneAnesthesia documents one intraoperative glucose measurement of 125. How would you report this? Enter 125 for lowest intraoperative glucose measurementEnter 125 for highest intraoperative glucose measurementEnter 125 for both highest and lowest intraoperative glucose measurementTwenty minutes after the patient returns to the ICU after the sampled OR case, the ICU documents the first postoperative temperature as 36.5C. How should you record this? Unknown (RATIONALE: the postop temperature must be within 15 minutes of out of room time)Known; Postoperative Temperature Unit: Celsius; Postoperative Temperature 36.5Not in RangePNEUMONIA (see chart on last page)What is the date of occurrence for this patient’s pneumonia?Date of Occurrence: 3/6Date of Occurrence: 3/7Date of Occurrence: 3/8Is this pneumonia a preoperative or postoperative event?Preoperative (RATIONALE: The DOO is before any eligible surgery)PostoperativeWhat date would the patient be eligible to assign another occurrence of pneumonia using the repeat infection timeframe? 3/123/20 (RATIONALE: RIT Day one is 3/6 + 14 days= 3/20. First eligible day is 3/20)3/213/22If the patient had a second occurrence of pneumonia, what date would you assign? Patient does not meet criteria for a second occurrence of pneumonia. Date of Occurrence: 3/12 (RATIONALE: Do not assign this date, it’s in the RIT)Date of Occurrence: 3/20Date of Occurrence: 3/21Date of Occurrence: 3/22POSTOP VARIABLESWhat is the date to capture for Lowest Postop HCT? 3/7 3/12 (RATIONALE: It doesn’t matter which case was sampled. 3/7 is a preop HCT since the first surgery was on 3/8, so is not correct. 3/12 is the first available date closest to after any of the of the surgeries. 3/22 reports the same value, but 3/12 is the first date after surgery the value is reported thus is the date to report.)3/22How would you report the Lowest HCT? Answer “No” to “Value in Range” and the date 3/12Answer “No” to “Value in Range” and the date 3/22Leave “Value in Range” as “Yes” and enter value 29.2 with date 3/12Leave “Value in Range” as “Yes” and enter value 29.2 with date 3/22What postop occurrences would you assign? Select all that applyPNA (3/20)Sepsis (no, report only highest level)Severe Sepsis (3/20: +PNA, lactic>2, HR>90, RR>20, WBC>12)DVT (RATIONALE No: > 30days postop from any of the OR dates) AKI (RATIONALE: Does not meet criteria to assign) PE [RATIONALE: 3/20 r/t +CT and heparin gtt started]PNEUMONIA (from questions 44-47)Dates3/23/33/43/53/63/73/83/93/103/113/123/173/183/193/203/213/223/23EVENTSAdmit, Surgery, Signs/Sx, CXR, CTADMOR#1OR#2OR#3WNLRR> 25RR> 25ralesRR>25RR>25Purulent secretions+CT w/ abx+CT+CTWBCWBCWBCWBC7-day Infection Window (IW)xxxxxxxxxxxxxxxxxxDate of Occ (DOO)xxxxxxPresent on Adm (POA)xxxxRepeat Infection Timeframe (RIT) 3/6+14 days = 3/20 earliest eligible date to assign PNA again ................
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