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									 DEPARTMENT: Clinical Services                    POLICY DESCRIPTION: Correction of Non-
 Group                                            editable Core Measure Data Elements in COMET

 PAGE: 1 of 2                                     REPLACES POLICY DATED: 11/1/09
 EFFECTIVE DATE: April 1, 2010                    REFERENCE NUMBER: QM.COM.002
 APPROVED BY: Ethics and Compliance Policy Committee

 SCOPE: All personnel responsible for performing, supervising or monitoring the Core Measure
 abstraction process within HCA-affiliated facilities including, but not limited to, hospitals, hospital-
 based outpatient surgery departments, and all Corporate Departments, Groups and Divisions.

 This policy applies to correction of non-editable Core Measure data elements. For information
 related to purging records for Core Measures see the Purging of Core Measure Records Policy,
 QM.COM.003.

 PURPOSE: To define the methodology and processes involved in the correction of non-editable
 Core Measure data elements in the Clinical Outcome Measures Evaluation and Transmission
 (COMET) application by facility abstractors.

 POLICY: The following data elements may not be edited by the COMET abstractor: Encounter
 Date, Procedure Code, Procedure Date, Diagnosis Code, Discharge Date, and Financial Class.

 Correction of these data elements can be accomplished by the submission of a data correction form to
 the Clinical Analytics department. Data Correction requests must be approved by the Manager of
 Data Quality. Data correction forms must be submitted before the purge deadline posted on Atlas
 published in the Core Measure abstraction schedule.

 If an identified non-editable element requiring a correction can be addressed internally through re-
 billing then completion of the procedure outlined within this policy would not be necessary. A Case
 Mix update will correct the data elements in COMET if the status of the record is active in accounts
 receivable (AR) in Patient Accounting. Once addressed internally, the COMET User Administrator
 or abstractor must track the noted data element to ensure an update occurs in COMET.

 The correction of a non-editable data element in COMET could result in the addition of another case
 being added during the normalization process. This may occur in order to reach the population
 sampling requirements. If another case is added into the sampling population, follow the routine
 abstraction process

 PROCEDURE: At the request of the facility through a data correction form, the HCA Clinical
 Analytics staff may request the data element be corrected by the COMET IT&S staff if approved.
 The following steps address the COMET User Administrator and the Corporate Manager of Data
 Quality responsibilities:

 1. Facility User Administrator or Abstractor
    a. The COMET User Administrator or abstractor should complete the data correction form
       published on the Clinical Analytics Atlas site and send to the Manager of Data Quality after
       the last Case Mix update of each quarter (listed on the abstraction schedule) if a correction
2/2010
 DEPARTMENT: Clinical Services                 POLICY DESCRIPTION: Correction of Non-
 Group                                         editable Core Measure Data Elements in COMET

 PAGE: 2 of 2                                  REPLACES POLICY DATED: 11/1/09
 EFFECTIVE DATE: April 1, 2010                 REFERENCE NUMBER: QM.COM.002
 APPROVED BY: Ethics and Compliance Policy Committee

        has not occurred through the Case Mix update (a typical time frame is 2 weeks).
     b. The data correction form has required fields in addition to the actual non-editable COMET
        data element requiring correction. All of these required fields i.e., those marked with an
        asterisk, must be completed in order to process the request form.
     c. Fax the supporting documentation with the data correction form to 866-260-0913 to the
        attention of the Manager of Data Quality, Clinical Services Group (CSG).
     d. The following COMET abstractor non-editable fields are not eligible for data correction
        requests since these fields are not submitted to The Joint Commission or the Centers for
        Medicare and Medicaid Services: “name,” “physician,” “medical record number,” and “social
        security number.”
     e. The record must remain in open status for the data correction to occur. Once the data
        correction has occurred, the COMET User Administrator or abstractor must set the record
        back to complete status

 2. Corporate Responsibilities
    The CSG Clinical Analytics Department will:
    a. Confirm receipt of the data correction request form via email
    b. Review all COMET data correction request prior to the close of the quarter.
    c. Contact the facility if questions or additional information is necessary.
    d. Notify the facility of the data correction determination.
    e. Send the data correction spreadsheet to IT&S for manual changes after the deadline posted in
       the abstraction schedule.
    f. Ensure data corrections do not occur after the aggregation of the Core Measure data at the end
       of the quarter.
    g. Monitor and trend all data correction request and conduct follow-up as necessary with a
       facility making multiple data corrections during a quarterly submission.
    h. Follow-up will occur with appropriate Corporate Departments if deemed necessary.
    i. Maintain a database of all data correction request , making it available to The Joint
       Commission upon request.

 REFERENCES:

 1. The Joint Commission-CMS Specifications Manual for National Hospital Quality Measures
 2. Core Measure Clarificaiton Process Documentation and Abstraction Education Policy,
    QM.COM.001
 3. Purging of COMET Core Measure Records Policy, QM.COM.003




2/2010

								
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