Thank you for viewing this CATH PCI Registry case scenario. In this scenario, we will cover sequence number 10116, Cardiac Rehabilitation Referral. A 60-year-old female patient was taken to the CATH lab and underwent successful PCI. Prior to discharge, an inpatient cardiac rehab nurse met with the patient and educated her about cardiac rehab in addition to providing her with an educational brochure. The question is, how would sequence number 10116, Cardiac Rehab Referral, be coded? One, no, reason not documented. Two, no, medical reason documented. Three, no, health care system reason documented. Or four, yes. Please take a few moments to review the documentation prior to making a final selection. The answer is number one, no, no reason documented. While an inpatient cardiac rehab nurse provided verbal and written education regarding cardiac rehab services, this does not inform the registry the healthcare provider recommended nor carried out a referral order to an early outpatient CR program, for example, Phase 2, which is needed to code yes. Additionally, as there is no documented medical or healthcare system reason why such a referral was not made or carried out on discharge, to satisfy the target value, no, reason not documented would be coded for sequence number 10116, cardiac rehab referral, as reasons could not be assumed or correlated. To code yes for sequence number 10116, cardiac rehab referral, documentation is needed on discharge to reflect that first, there was communication between the healthcare provider and the patient to recommend and carry out a referral order to an early outpatient CR program and that that took place. This is not met by providing education about the program. This is met when there is documentation reflecting a recommendation by their healthcare provider to attend the program and carry out the referral process with evidence of providing all necessary information to the patient, which will allow them to enroll in a CR program and either written or electronic communication between the healthcare provider or the healthcare system and the cardiac rehab program that includes the patient's enrollment information for the program. A hospital discharge summary or office note may potentially be formatted to include the necessary patient information to communicate to the CR program, for example, the patient's cardiovascular history, testing, and treatments. All communications must maintain appropriate confidentiality as outlined by the 1996 Health Insurance Portability and Accountability Act. The definition of sequence number 10116, cardiac rehab referral, was taken directly from the update on performance measures on cardiac rehab for referral to cardiac rehabilitation slash secondary prevention services. This is available online via a Google quick search. We will provide more education for you to digest, which ultimately reflects the fact that we are doing all of this hard work as it's in the best interest of the patient. Firstly, a key component to outpatient CR program utilization is the appropriate and timely referral of patients. Generally, the most important time for this referral to take place is when the patient is hospitalized for a qualifying event or diagnosis such as MI, CSA, CABG, PCI, cardiac valve surgery, or cardiac transplantation. An effective referral or appropriate inpatients to the outpatient CR program is the responsibility of the healthcare team within a healthcare system that is primarily responsible for providing cardiovascular care to the patient during the hospitalization. The performance measure was developed to help healthcare systems implement effective steps in their systems of care that will optimize the appropriate referral of a patient to an outpatient CR program. Thank you for viewing this CAF-PCI registry case scenario.

emergency department

chest pain

difficulty breathing

ST elevation

heart failure

video

sequence number 10116

cardiac rehabilitation referral

referral coding

outpatient CR program