0321 - Sequence # 9002 | (Intra/Post-Procedure Events Occurred - Bleeding: Access Site)-0321 - Sequence # 9002 | (Intra/Post-Procedure Events Occurred

Video Transcription

Welcome to the STS-ACC TVT Registry March Case Scenario for Version 3. This month we will cover Sequence 9002, Intra-Post-Procedure Events Occurred, Leading Access Site.  A 60-year-old female presented for elective TAVR. After successful valve delivery, her right femoral valve delivery site received a perclose.  The following day, the patient voiced no complaints. Her groin checks demonstrated no ecchymosis, oozing, or hematoma.  However, her hemoglobin dropped 3.4 grams per deciliter within 24 hours of her TAVR procedure.  How would Sequence 9002, Intra-Post-Procedure Events Occurred, be coded for Leading Access Site? No or Yes?  Please take a moment to review the documentation and the question prior to making a final selection.  The answer is number one, No. Sequence 9002, Intra-Post-Procedure Events Occurred, would be coded as No for Leading Access Site.  Per the data definition, there is no indication of an observed and documented external bleed at the access site in the medical record to support the coding of this data element.  In order to code Yes to Sequence 9002, Intra- and Post-Procedure Events Occurred, Bleeding Access Site, there must be documentation that the patient experienced external bleeding  at the access site that was observed and documented in the medical record to support coding, meeting  the target value of any occurrence between start of procedure and until next procedure or discharge. Then, once identified, there must be any one of the following to qualify.  Hemoglobin drop of greater than or equal to 3 grams per deciliter, transfusion of whole blood or packed red blood cells, or procedural intervention or surgery at the bleeding site  to reverse, stop, or correct the bleeding, such as surgical closures, exploration of the arteriotomy site, balloon angioplasty to seal an arterial tear, endoscopy with cautery  of a GI bleed. Thank you for viewing the March 2021 STS-ACC TVT Registry Case Scenario.

Video Summary

The video is a case scenario for the STS-ACC TVT Registry. It focuses on Sequence 9002, Intra-Post-Procedure Events Occurred, specifically regarding the leading access site. A 60-year-old female underwent a TAVR procedure, and her right femoral valve delivery site was closed with a perclose. The patient did not experience any external bleeding or complications at the access site, but her hemoglobin levels dropped by 3.4 grams per deciliter within 24 hours of the procedure. The question posed is whether Sequence 9002 should be coded as No or Yes for the leading access site. The answer provided is No, as there is no documented external bleed to support coding for this data element. To code Yes, there must be documentation of observed bleeding at the access site, along with specific criteria such as a significant hemoglobin drop, transfusion, or procedural intervention.

Keywords

STS-ACC TVT Registry

Sequence 9002

Intra-Post-Procedure Events Occurred

leading access site

TAVR procedure