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1223 - Sequence # 15490 | Cerebral Performance Cat ...
1223 - Sequence # 15490 | Cerebral Performance Cat ...
1223 - Sequence # 15490 | Cerebral Performance Category (CPC) Score
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Video Transcription
The December 2023 case scenario for the chest pain MI registry reviews cerebral performance category, CPC, score. Female of 57 years of age with chest pain presents via EMS with STEMI positive ECG. Initial assessment per EMS says the patient is alert and oriented times three and diaphoretic. Temperatures are 36.7 Celsius. Heart rate is 102 beats per minute. Blood pressure is 181 over 94. Respiratory rate is 29 breaths per minute. The pulse ox is 92% on room air, and a BiPAP was initiated. Upon arrival to the ED, she is confused, and her skin is cool and clammy to the touch. Repeat vitals reveal heart rate of 112, blood pressure of 84 over 40, pulse ox of 85% on non-rebreather, and she quickly deteriorates. Simultaneously, a fluid bolus administered. Intubation is initiated. The patient is sedated. Intubated with intravenous propofol to be titrated as needed to keep the patient sedated. Air ambulance transport is arranged. Patient experiences V-fib arrest, CPR initiated, and returns for a perfusing rhythm with one defibrillation shock. Thrombolytics initiated while stabilization efforts continue. The flight crew arrive, and the patient is transferred to PCI-capable hospital. Question number one, how is sequence number 15490, cerebral performance category, CPC score, coded for the referral hospital? One, score of one, good cerebral performance. Two, score of two, moderate cerebral disability. Three, score of three, severe cerebral disability. Four, score of four, coma or vegetative state. Five, score of five, brain death. Please pause and take a few moments to make the best selection. The answer to question one is the selection number four, a score of four, coma or vegetative state. Patients that experience a cardiac arrest who are discharged alive and sedated, sequence number 15490, CPC score, is coded by selecting the CPC score of four, coma or vegetative state. The patient arrived at the receiving hospital The patient arrived at the receiving hospital via ambulance flight. She was taken directly to the cath lab with the intent of immediate PCI. The patient was prepped and coronary angiogram performed, revealing proximal LAD occlusion of 90%. Immediately after the initial insertion of the interventional wire in the femoral artery, the patient experiences V-fib arrest. CPR with multiple defibrillations ensue. Cardiac arrhythmia deteriorates to asystole. Multiple doses of epi are administered without a cardiac response. After 45 minutes of resuscitation efforts, the patient is pronounced dead. How would sequence number 15490, cerebral performance category, CPC score, be coded for the receiving hospital? One, a score of one, good cerebral performance. Two, a score of two, moderate cerebral disability. Three, a score of three, severe cerebral disability. Four, score of four, coma or vegetative state. Or five, score of five, brain death. Again, take a few moments to review the information before you make a decision. The answer to this question is selection number five, brain death. In the scenario of a patient who has experienced a cardiac arrest and is discharged deceased, brain death is selected. Although CPC scores are collected at centers worldwide for use in comparing outcomes, evaluating therapies, and formulating recommendations, no formal standardized training is offered in calculating CPC scores. Thus, documentation found in the patient's legal medical record is used for coding the CPC score when the data definition and the target value are met, and it must be present in the event of an audit. Descriptive documentation in the medical record can be used for coding the CPC score and includes and not limited to physician or nurse documentation. Additionally, the data abstractor can make the determination based on the documentation in the medical record. Thank you for viewing the Chest Pain in My Registry December 2023 case scenario.
Video Summary
In this video, two case scenarios are discussed regarding the coding of the cerebral performance category (CPC) score for patients who experience cardiac arrest. In the first scenario, a female patient arrives at the referral hospital and is coded with a CPC score of four, indicating a coma or vegetative state. In the second scenario, a patient is taken to a receiving hospital for immediate PCI after a cardiac arrest. However, despite resuscitation efforts, the patient is pronounced dead, and the CPC score assigned is five, indicating brain death. It is emphasized that the CPC score should be based on the documentation in the patient's medical record.
Keywords
June 2023 case scenario
P2Y12 inhibitors at discharge
metric 46
eReports dashboard executive summary
64-year-old female patient
video
coding
cerebral performance category
cardiac arrest
CPC score
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