The Chespin and MyRegistry March 2020 case scenario is reviewing Sequence 10116, Cardiac Rehabilitation Referral, and its impact on Metric 21 Cardiac Rehabilitation Referral from an inpatient setting. An 88-year-old female presented with increased altered mental status and decreased level of consciousness. She is admitted with a non-stemic clinical diagnosis and a rise in troponin I within 24 hours of arrival. The family refuses all invasive procedures and the cardiologist treats her medically. The discharge summary states, recommends skilled nursing facility. Question, how is Sequence 10116, Cardiac Rehabilitation Referral, coded? 1. No reason not documented. 2. No healthcare system reason documented. 3. No medical reason documented. 4. No patient-oriented reason. Or 5. Yes. Please take a few moments to review the documentation and question and available answers. Question, how is Sequence 10116, Cardiac Rehabilitation Referral, coded? And the correct answer is 1. No reason not documented. The rationale to code no medical reason, no patient reason, or no healthcare system reason for Cardiac Rehabilitation Sequence 10116 requires specific documentation in the medical record indicating why a Cardiac Rehabilitation Referral is not provided. Although the patient is discharged to a skilled nursing facility, the requirement of a documented reason remains. The chest pain in my registry does not support implied coding. The data abstract are correctly coded as follows. Discharge status, alive. Cardiac Rehabilitation Referral, no reason not documented. And discharge location as skilled nursing facility. The available coding selections of Sequence 10116, Cardiac Rehabilitation Referral, and their definitions. No patient-oriented reason that precludes a referral to Cardiac Rehabilitation, meaning no traditional Cardiac Rehabilitation program available to the patient within 60 minutes travel time from the patient's home, or the patient does not have an alternative model of Cardiac Rehabilitation delivery that meets all the criteria for the Cardiac Rehabilitation program. No medical reason documented. The patient is deemed by the medical provider to have a medical unstable life-threatening condition or has a cognitive or physical impairment that precludes Cardiac Rehabilitation participation. No healthcare system reason documented. Patient is discharged to a nursing care or long-term care facility, or patient lacks medical coverage for Cardiac Rehabilitation program. The chest pain in my registry, metric 21, Cardiac Rehabilitation Referral, mirrors the writing committee's 2018 ACC AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation, specifically performance measure number one, referral from an inpatient setting. This includes denominator exceptions for Cardiac Rehabilitation. This includes denominator exceptions when there is documentation to support either a patient reason, medical reason, or healthcare system reason. This document is located in the chest pain in my registry's resources link by selecting documents under the heading of quality tools and reference documents. Metric 21, Cardiac Rehabilitation Referral from an inpatient setting, is found in the executive summary measures and metrics document and is located in the chest pain in my registry's resource link by selecting documents under the heading of quality tools and reference documents. This patient meets the denominator criteria for metric 21 as all non-STEMI inpatient STEMI patients who do not have a documented reason as to why Cardiac Rehabilitation was not provided, a denominator exception, or one of the exclusions listed will be included. The patient is listed as no in the numerator as she did not receive a referral nor there was no documentation in the medical record indicating why a referral was not provided. Thank you for viewing the chest pain in my registry March 2020 case scenario reviewing sequence 10,116 Cardiac Rehabilitation Referral and metric 21 Cardiac Rehabilitation Referral from an inpatient setting.

Cardiac Rehabilitation Referral

Metric 21

inpatient setting

discharge summary

coding requirements