Welcome to the STS-ACC TBT Registry Case Scenario. This will be our first case scenario for the Version 3 upgrade. This month we will discuss a new data element, Cardiac Rehabilitation Referral Sequence 10116. In this scenario, a 60-year-old female was admitted for a TAVR, which was successful. Prior to discharge, a recommendation to attend a Phase II cardiac rehabilitation program as an outpatient was provided as directed by his cardiologist. Prior to discharge, the cardiac rehabilitation nurse met with the patient to discuss the reason for the referral, and the patient was provided information about the program. An offer to send the referral to the nearest cardiac rehabilitation facility was made. However, she adamantly refused as her work schedule would conflict, and she stated she was unable to miss work. How would Sequence 10116, Cardiac Rehabilitation Referral, be coded? 1. No, reason not documented 2. No, medical reason documented 3. No, healthcare system reason documented 4. No, patient-oriented reason or 5. Yes. Please take a moment to review the documentation and the question prior to making a final selection. Sequence 10116 would be coded as Yes. In this scenario, there was communication with the healthcare provider and the patient of the cardiac rehab recommendation, and there was documentation in the medical record of the patient refusal to attend cardiac rehab. Sequence 10116, Cardiac Rehabilitation Referral, indicates if there was written documentation of a referral for the patient by the physician, nurse, or other personnel to an outpatient cardiac rehabilitation program. Per the 2018 ACC AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation, a referral is defined as 1. Documented communication between the healthcare provider and the patient to recommend an outpatient cardiac rehabilitation program and 2. A. Official referral order is sent to outpatient cardiac rehabilitation program or 2. B. Documentation of patient refusal to justify why patient information was not sent to the cardiac rehabilitation program. Performance is met if Steps 1 and either 2. A. Official referral order transmitted or 2. B. Patient refusal documented in the patient's medical record are completed and documented. All communications must maintain appropriate confidentiality as outlined by the Health Insurance Portability and Accountability Act of 1996. In this scenario, no patient-oriented reason would not be selected because neither of the below criteria are met. 1. No traditional cardiac rehabilitation program available to the patient within 60 minutes travel time from the patient's home or 2. Patient does not have access to an alternative model of cardiac rehabilitation delivery that meets all criteria for a cardiac rehabilitation program. Thank you for viewing the January 2021 STS-ACC TBT Registry Case Scenario.

TAVR procedure

cardiac rehabilitation program

referral

patient refusal

patient confidentiality