Thank you for reviewing the chest pain MI registry case scenario for August of 2023, where we will discuss sequence 15452, Canadian Study of Health and Aging, CSHA Clinical Frailty Scale. A 39-year-old female is outside training for a half marathon during her lunch hour when she experienced unexplained, abrupt, severe shortness of breath. She is so short of breath she is unable to continue and decides she must cut her training short despite the marathon only being two weeks away. She returns to her office and after resting, her shortness of breath does not completely resolve. Her coworkers become concerned and call 911. Upon EMS arrival, she is sitting in a chair at her desk in visible respiratory distress. An immediate ECG is performed, which reveals ST elevations. Her vital signs are as follows, blood pressure 140 over 110, heart rate is 112 beats per minute, and her O2 saturation is 92% on room air. She has no medical history with no medications prescribed. The decision to transport to the nearest emergency department is made, and she requires assistance to move from her chair to the EMS stretcher. The triage nurse notes continued shortness of breath and places her on two liters of oxygen, raising her O2 sat to 97%. Her lungs are clear. She is awake and alert, times three, with warm and dry skin to touch. She is wheeled to room 15, where she requires assistance out of the EMS stretcher to the ED stretcher due to her symptoms. An EMS ECG is given to the ED physician who notes the ST elevations are consistent with an anterior MI. The cath lab is activated, and troponins are obtained. Question number one, when there is no specific documentation identifying the patient's frailty status, can descriptive documentation be used to code sequence 15452 CSHA frailty scale? Number one, no. Or number two, yes. Please take a few moments to review this question prior to making your final selection. And the answer is number two, yes. Descriptive documentation of the patient's current condition in the medical record that meets the definition is satisfactory. As an example, the patient reports they are normally active but unable to ambulate on arrival due to pain. As well, physician documentation of a specific frailty scale will support coding. Question number two, what documentation in the medical record can be used for coding sequence 15452? Number one, physician documentation. Number two, nursing documentation. Number three, EMS documentation. Or number four, any. We'll provide a few moments for you to review the question and the selections prior to making your final determination. And the answer is number four, any. Documentation found anywhere in the patient's legal medical record is used for coding the CSHA frailty score when the data definition and the target value are met, as this must be present in the event of an audit. Question number three, how is sequence 15452 CSHA clinical frailty scale coded based on the documentation available? Number one, well. Number two, vulnerable. Or number three, moderately frail. Please take a few moments to review the documentation prior to making your final selection of well, vulnerable, or moderately frail. And the answer is number two, vulnerable. Let us review the documentation and put it all together to determine why the selection of vulnerable is the most appropriate selection. The Canadian Study of Health and Aging, or CSHA, clinical frailty scale in sequence 15452 is capturing the value on arrival. In other words, the most recent symptoms and clinical status of a patient will impact how this data element is coded. This is not an assessment of the patient's baseline. Documentation anywhere within the facility's medical record is acceptable. For those who participate in CAF PCI as well as chest pain MI, you may use the documentation that supports the coding of CAF PCI sequence 4561 CSHA frailty scale to code chest pain MI's sequence 15452 CSHA frailty scale when there is no change in symptoms or clinical status despite the difference in the target values. So let's take a moment to review this scenario. The patient is an active female who is overall healthy and has no prior medical history and takes no medications on a daily basis. However, her symptoms of shortness of breath now limits her ability to do previous simple activities like moving from a stretcher to another stretcher. And this is now the frailty status we want to capture. It is important to refer to the infographic for the CSHA clinical frailty scale located in the resources link within documents. In this scenario, this patient meets the descriptive definition of vulnerable with their status on arrival to the facility. Thank you for reviewing the chest pain MI case scenario.

June 2023 case scenario

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