CPMI-1224 - Sequence # 10116 | Cardiac Rehab Referral-1224 - Sequence # 10116

1224 - Sequence # 10116 | Cardiac Rehab Referral

Video Transcription

Video Summary

In December's chest pain MI registry review, a 78-year-old male with extensive medical history, including stage 4 dementia, received a coronary atherectomy after a suspected cardiac incident. Despite routine post-procedure orders recommending cardiac rehabilitation, he was found too physically weak, and no referral was made. The case highlights coding for cardiac rehabilitation referrals, explaining that "no reason not documented" was the correct coding choice because the necessary documentation for other coding options (like medical instability or discharge to a care facility) was not provided. Proper documentation of discussions or referrals prior to discharge is essential for coding.

Keywords

shared decision making

chest pain

nuclear stress SPECT

MI Registry

EHR documentation

cardiac rehabilitation

coronary atherectomy

coding documentation

medical history

dementia