CPMI-1026 - Seq. 10116 (Cardiac Rehabilitation Referral) v3.2-CPMI-1026

Video Transcription

Video Summary

A 78-year-old woman with NSTEMI, PCI, and TAVR had an inpatient cardiac rehab consultation, but no outpatient cardiac rehabilitation referral order was placed before discharge. The record noted the patient and family needed time to consider rehab, but did not document a refusal, a medical reason preventing referral, or a healthcare system reason linked to the absence of referral. Therefore, Sequence 10116, Cardiac Rehabilitation Referral, should be coded as 2: no, reason not documented. The key principle is to code only what is explicitly documented, not what is inferred from the clinical situation.

Keywords

NSTEMI

PCI

TAVR

cardiac rehabilitation

referral documentation