Hello everyone and welcome back to our bimonthly case scenario for October of 2024. For this case scenario, we will examine and expand on how to code shared decision-making. The LAAO registry did an initial shared decision-making case scenario in October of 2022 and since that time, multiple questions continue to come into the registry. We have decided to take another look at this data element and include bonus questions of additional questions that have been asked. A 74-year-old male presents for their LAAO procedure. The history and physical examination notes that the LAAO procedure was discussed with the patient by the interventional cardiologist prior to entering the procedure room. The risks and benefits of the procedure were discussed and reviewed with the patient. At the end of the conversation, the patient verbalized understanding and agreed to the procedure with assigned consent. There was no additional documentation of a patient-physician conversation concerning the procedure or alternative treatment options in the medical record. So our question is, how is sequence 14.732 shared decision-making coded? Number 1, no, or number 2, yes. Please take a moment to review the documentation and the question before making your final answer. The answer is number 1, no. The reasons that the documentation does not meet the national coverage determination criteria are that the documentation shows that the interventional cardiologist who was performing the procedure was the person who discussed the procedure with the patient. This does not meet the NCD guidelines that state an independent non-interventional physician conducts the interaction. Two, an evidence-based decision-making tool was not documented. Three, there was no shared decision-making interaction documented in the medical record. What has occurred in this example is informed consent and not an example of shared decision-making. Per the decision memo for percutaneous left atrial appendage closure therapy, which is located on the document's homepage, shared decision-making is coded on a shared decision-making interaction concept is coded on a shared decision-making interaction conversation with an independent non-interventional physician using an evidence-based decision-making tool on oral anticoagulation in patients with non-valvular atrial fibrillation prior to the left atrial appendage closure procedure. Additionally, the shared decision-making interaction must be documented in the medical record. It is important to understand the shared decision-making process is part of the CMS national coverage determination and therefore a requirement of CMS for LAAO procedures. The registry is capturing the documentation of the process. Before proceeding with our bonus questions, we wanted to take a minute and define the difference between informed consent and shared decision-making. Informed consent is not synonymous with shared decision-making. Informed consent is a description of the planned procedure or surgery with the explanation of risks and benefits. This is a process of obtaining the patient's permission to proceed. Shared decision-making is a patient-centered conversation where the clinician and patient work together to map out the best course of action based on patient preferences as it relates to the clinical evidence. It is a process in which both the patient and the physician contribute to the medical decision-making process and agree on treatment decisions. This is shown to increase the knowledge and satisfaction regarding care, define clearer goals for treatment, and to align health decisions with patient values. Please work with providers and your local CMS representative to determine a process of documentation that will allow for the coding of shared decision-making as this cannot be left to the interpretation of the abstractor or the LAAO registry. Some documentation to look for that may help with coding. Ensure that a non-interventional provider conducts the interaction. A statement by the provider that a shared decision-making encounter occurred with a non-interventional provider is sufficient for coding yes. The use of an SDM tool would allow for the coding of sequence 14732 as yes. Using a smart phrase within the facility's EHR system regarding SDM by the NIP is sufficient for coding as yes, in addition to easing the burden of documentation and data abstraction. Using the same documentation as the initial question, we will ask a few questions that have been sent in on additional aspects of coding shared decision-making. Bonus question number one, what does the term non-interventional physician provider mean? The answer, a physician provider who does not have privileges to perform an LAAO procedure. Communicating with facilities and providers, we have learned that in most cases, the referring general cardiologist is asked to perform the shared decision-making process while other providers have the patient meet with a non-interventional provider in the same practice. Bonus question number two, can advanced practice physicians and fellows provide shared decision-making with documentation for the registry guidelines? There's no specific information on this in the data dictionary. And the answer, the NCD states the provider can be the primary care provider, but does not mention if a non-interventional cardiologist, fellow, NP, PA, or a non-EP interventionalist can be part of the process. We recommend referring to your provider and or your local CMS representative to obtain more details of the process. Bonus question number three, the NCD states that shared decision-making is coded on a shared decision-making interaction conversation with an independent non-interventional physician using an evidence-based decision-making tool on oral anticoagulations in patients with non-valvular atrial fibrillation. Where can I find a list of acceptable evidence-based decision-making tools on the website? And the answer, at this time, there isn't a specific tool that is being coded in the registry as the team is evaluating possible choices to add. As of now, the only choice in the elements dropdown menu is other shared decision-making tool. However, we do wanna share that from our communications with participants, the tools that are most often used are the NICE tool and the AFib stroke prevention tool found in CardioSmart. Links are provided below, but are not listed in the shared decision-making tool data element. The NICE tool was mentioned in the NCD as a shared decision tool option, and the link is provided here. And we also have a tool in our CardioSmart website and the link is provided here as well. We thank you for taking the time to review our latest case scenario. We'll see you for the next case scenario in December. Thank you.

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