This is a cath PCI case scenario for March 2020, sequence number 10116, Cardiac Rehabilitation Referral. A 70-year-old male with a history of multivessal disease presents for an elective PCI. The physician is unable to cross the lesion with the guide wire and no devices are used. The patient is discharged from the facility and instructed to continue the current medication regime and are provided a referral to the cardiothoracic surgeon for possible cabbage. During the coding process, the abstract denotes that there is no documentation for cardiac rehab. When clarifying with the physician, he states, no rehab because no PCI was done. How is Sequence 10116, Cardiac Rehabilitation Referral, coded? 1. No, reason not documented. 2. No, medical reason documented. 3. No, health care system reason documented. 4. Yes. And the answer is, number one, no, reason not documented. Sequence 10116, Cardiac Rehab Referral, captures when the patient is given a referral at discharge to an outpatient cardiac rehabilitation program or a documented medical reason or patient-centered reason why such a referral was not made. When a referral to an outpatient Phase II cardiac rehabilitation program is not provided to the patient at discharge and there is no medical reason, patient-centered reason, and or health care system documented in the patient's medical record as to why one was not provided, then no, reason not documented is coded. To clarify, the CAHPS PCI Registry captures all PCIs both attempted and or performed and all associated PCI data elements are relevant and required fields. The expectation then becomes that a cardiac rehab referral is provided for this subset of patients. The CAHPS PCI Registry uses practice guidelines to assist health care providers in clinical decision-making processes for patients undergoing PCIs attempted and or performed, the goal being to improve quality of care. The recommendation is 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. Participating in cardiac rehabilitation is associated with significant reduction in all-cause mortality. When the physician believes it is not in the best interest of the patient and provides supporting documentation of a medical reason for not providing a referral at discharge, then no medical reason documented would be coded for sequence 10116. No health care system reason documented would be coded when there is supporting evidence that there is no outpatient phase 2 cardiac rehab programs within 60 minutes of travel from the patient's home. Any patient-centered reasons, such as a patient refusing to participate and 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 10116. In the given scenario, because the patient is an attempted PCI and there is no supporting documentation of a medical reason for not providing a cardiac rehab referral and or a health care system reason for not providing a cardiac rehabilitation referral at discharge, the patient is not included in the numerator for metric 45. Thank you for viewing the CAHPS PCI Registry Monthly Case Scenario for March 2020, sequence number 10116, Cardiac Rehabilitation Referral.

elective PCI procedure

cardiac rehab referral

coding process

documentation

reduce all-cause mortality