Welcome to the February 2025 case scenario for the Cath PCI Registry, where we will review sequence number 10116, Cardiac Rehabilitation Referral. A 70-year-old male with a history of multivessel disease presents for an elective PCI. The physician is unable to cross the lesion with the guidewire, and no devices are deployed. The patient is discharged from the facility and instructed to continue the current medication regimen, and referral is provided to the cardiothoracic surgeon for possible cabbage. During the coding process, the abstractor notes that there is no documentation for cardiac rehab. When clarifying with the physician, the physician states, not appropriate for cardiac rehab referral. Our question is, how is sequence number 10116, Cardiac Rehabilitation Referral, coded? Number one, no, reason not documented. Number two, no, medical reason documented. Number three, no, healthcare system reason documented. Or number four, yes. Please take a few moments to review the documentation prior to making your final determination. And the answer is number two, no, medical reason documented. And the rationale is that the provider documentation demonstrates the following. They did not forget to provide a referral, and their medical assessment was that the patient should not participate in cardiac rehab, which supports that there was a medical reason for not providing the cardiac rehab referral. When a live is coded in sequence 10105, Discharge Status, capturing the patient's status on discharge, then the child-filled sequence 10116, Cardiac Rehabilitation Referral, captures if there was written documentation of a referral for the patient to an outpatient cardiac rehabilitation program, or a documented medical or patient-centered reason why such a referral was not made. In the scenario provided, as PCI was attempted and the physician documented not appropriate for referral, this supports coding no medical reason documented for sequence 10116. To provide some additional clarification, the CAF PCI registry captures all PCIs, both attempted and or performed, and all associated PCI data elements are relevant and required fields. And the expectation then becomes that a cardiac rehab referral is provided for this subset of patients. The CAF PCI registry uses practice guidelines to assist healthcare providers in the clinical decision-making process for patients undergoing PCI, attempted and or performed, the goal being to improve quality of care. 2011 practice guidelines provide the recommendation that medically supervised exercise programs should be recommended to patients after PCI, particularly for patients at moderate to high risk for whom supervised exercise training is warranted. Participation in cardiac rehabilitation is associated with significant reduction in all-cause mortality and cardiac mortality. When the physician believes it is not in the best interest of the patient and provides documentation of cardiac rehab referral indicating not appropriate, not indicated, contraindicated, etc., then for the purposes of the registry, this supporting documentation is sufficient to code no medical reason documented for sequence 10116. When abstracting this form of documentation, the registry supports the provider's medical reason and rationale for not providing a cardiac rehab referral at discharge for the patient. If there is additional documentation that provides the reason the referral was not indicated, then this additional information may assist in further determining whether the reason for not prescribing a referral was a medical reason or a healthcare system reason. In the given scenario, because the patient is an attempted PCI and there is supporting documentation of a medical reason for not providing a cardiac rehab referral and or a healthcare system reason for not providing the referral, the patient is removed from the denominator. Let's review. A referral is defined as an official communication between the healthcare provider and the patient to recommend and carry out a referral order to an early outpatient cardiac rehab program. This includes the provision of all necessary information to the patient that will allow the patient to enroll in an early outpatient cardiac rehab program. For instance, the cardiac rehab name, telephone number, address, etc. This also includes a written or electronic communication between the healthcare provider or healthcare system and the cardiac rehabilitation program that includes the patient's enrollment information for the program. The hospital can transmit this information or provide evidence that the patient was instructed to hand-carry this information to their first appointment. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the cardiac rehab program. As an example, the patient's cardiovascular history, testing, and treatments. All communications must maintain appropriate confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act. When there is documentation or a note that the above took place prior to discharge, that is sufficient to code yes. Documentation by the provider of cardiac rehab referral not indicated, not appropriate, contraindicated, etc. supports coding no medical reason documented. Supporting evidence that there is no outpatient phase 2 cardiac rehab programs within 60 minutes of travel from the patient's home supports coding no healthcare system reason documented. Additionally, any patient-centered reasons, such as the patient refusing to participate or attend in an outpatient cardiac rehab program, should not prevent or prohibit the physician in providing a referral to the patient at discharge. When a referral is provided to the patient at discharge and the patient refuses and there is supporting documentation in the medical record, then yes is coded to Sequence 10-116. Thank you for viewing the CAHPS PCI Registry Monthly Case Scenario for February of 2025.

cardiogenic shock

STEMI

Impella

PCI salvage

CPR

PCI Registry

cardiac rehabilitation

medical documentation

quality care

guidelines

Cath PCI Registry

medical rationale

documentation

patient care quality