The December case scenario for the chest pain MI registry will review sequence 10116, cardiac rehabilitation referral. A 78-year-old male presents via EMS with his daughter present after a syncopal episode, followed by presumed chest pain, as noted by the patient clutching his chest. The EMS ECG is negative for STEMI. The initial troponin value obtained is greater than the 99th percentile. The patient has an extensive past medical history. That includes hypertension, dyslipidemia, diabetes mellitus type 1, coronary artery graft surgery, stage 2 colon cancer, which was surgically treated, and he is currently receiving radiation treatments, as well as stage 4 dementia. Due to the patient's cardiovascular history, a coronary angiogram was recommended after a shared decision-making discussion with the daughter and the patient. A coronary angiogram is performed, which reveals an obstruction to the LAD proximal saphenous vein graft touchpoint. A percutaneous transvenous coronary atherectomy was performed. The routine post-procedure orders included a cardiac rehabilitation referral consult. The cardiac rehabilitation nurse discusses with the patient and his daughter, and documents in the progress notes, cardiac rehab referral is not recommended, as the patient is physically weak and has stage 4 dementia. At discharge, a cardiac rehabilitation referral was not provided. Our question is, how is cardiac rehabilitation referral coded? Number one, yes. Number two, no, reason not documented. Number three, no, medical reason documented. Number four, no, healthcare system reason documented. Or number five, no, patient-oriented reason. Please take a few moments to review the documentation to make your final determination. The correct answer is number two, no, reason not documented. Let's review why no reason not documented is the correct selection, while also exploring why the other selections are not correct. Yes is not the correct selection. To code yes, there must be a discussion where the referral is then provided or documentation of the patient's refusal. Per the 2018 ACC AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation, a referral is defined as either 1 and 2A, documented communication to recommend a cardiac rehabilitation referral, an official order sent to an outpatient cardiac rehabilitation program, or 1 and 2B, documented communication to recommend a cardiac rehabilitation referral and documentation of the patient's refusal. In this scenario, neither referral for cardiac rehabilitation was provided, nor was there documentation of the patient's refusal. Performances met if steps 1 and either 2A, official referral order transmitted, or 2B, patient refusal documented in the patient's medical record, are completed and documented. When the performance is met, then yes is coded. Let us continue to review the selections based on the scenario and the rationale as to why no, no reason is the correct selection. No medical reason documented is also not the correct selection. To code no medical reason, there must be documentation from a medical professional or advanced practice practitioner deeming the patient medically unstable, to have a life-threatening condition, or has other cognitive or physical impairments that preclude cardiac rehabilitation participation. The documented medical reason must be linked to why the cardiac rehabilitation was not provided or documented in one continuous thought. In this scenario, the medical professional or an advanced practice practitioner did not deem the patient to be medically unstable or have a life-threatening condition precluding the cardiac rehabilitation participation. The requirement to have documentation from an advanced practice practitioner for a medical reason was established in the 2018 ACC AHA Clinical Performance Quality Measure for Cardiac Rehabilitation Published Performance Measures. No healthcare system reason documented would also not be the correct selection for this scenario. To select no healthcare system reason, there must be documentation linking the patient is being discharged to a nursing care or long-term care facility, or the patient lacks medical coverage for cardiac rehabilitation. The documented healthcare system reason must be linked to why the cardiac rehabilitation was not provided or documented in one continuous thought. There is no documentation of the patient being discharged to a nursing care center or long-term care facility, and there is no documentation to support the patient did not have medical coverage that precluded cardiac rehabilitation referral. Therefore, no healthcare system reason is not the correct selection. No patient-oriented reason would also not be a correct selection. To select no patient-oriented reason, there must be documentation of no traditional cardiac rehabilitation program available to the patient within 60 minutes travel time from the patient's home, or patient does not have access to an alternative model of cardiac rehab delivery that meets all criteria for a program. The documented patient-oriented reason must be linked to why the cardiac rehabilitation was not provided or documented in one continuous thought. To recap, to code no medical reason, no patient-oriented reason, or no healthcare system reason for cardiac rehab, sequence 10.1.1.6 requires specific documentation in the medical record indicating why cardiac rehabilitation referral is not provided. No medical reason documented requires documentation from an advanced practice practitioner. The selections shown below are implicit and require documentation in the medical record to support coding. No medical reason documented patient deemed by a medical provider to have a medically unstable life-threatening condition or has other cognitive or physical impairments that preclude cardiac rehab participation. No healthcare system reason documented patient is discharged to a nursing care or long-term care facility or the patient lacks medical coverage for cardiac rehab. No patient-oriented reason, no traditional cardiac rehab program available to the patient within 60 minutes travel time from the patient's home, or the patient does not have access to an alternative model of cardiac rehab delivery that meets all criteria for a program. No reason not documented is the correct selection. Some additional insight to share, it is required to have a referral, discussion, and transmission of the referral and pertinent information to a cardiac rehabilitation facility to meet all of the criteria. The referral and discussion are required to be completed prior to discharge. The transmission of the referral and pertinent information may occur after discharge, however, the expectation is that all will be completed prior to discharge. All patient information required for enrollment should be transmitted to the cardiac rehab program. The 2018 ACC AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation PM1 explains that for compliance purposes, the patient's overall health is improved if they receive the referral prior to discharge. Thank you for viewing the Chest Pain MI Registry December 2024 case scenario.

shared decision making

chest pain

nuclear stress SPECT

MI Registry

EHR documentation

cardiac rehabilitation

coronary atherectomy

coding documentation

medical history

dementia