Welcome, and thank you for joining this learning activity titled CVASC Registry Education to Sequence Numbers. This is a learning activity with focused education on the sequence numbers in the permanent pacemaker portion of the CVASC registry. After participation in this learning activity, the learner should be able to identify, discuss, and explore the sequence number elements in the permanent pacemaker portion of the registry. This presentation includes many elements at once and is provided as baseline education. In addition to this education, the user can search individual portions of this presentation by accessing individual videos using the search functionality provided. We thank you for choosing the American College of Cardiology's CVASC registry, and we'd like to welcome you to the team. If you have any questions after watching these educational resources, please let us know via the Contact Us feature on your registry homepage. Now buckle in for some educational time as we navigate the sequences in the registry. Sequence 3001, Arrival Date and Time, is captured on all cardiovascular-eligible procedures entered in each facility's cardiovascular ASC data collection tool. Its intent is to capture the earliest indicator that the patient arrived at your facility and will serve as a tool to confirm the patient is at 18 years of age upon arrival to meet eligibility criteria. This data element can also assist in determining wait times and throughput to understand efficiencies and deficiencies. Facility Classification Type is captured on all eligible cardiovascular procedures entered in each facility's cardiovascular ASC data collection tool. This type may be either Ambulatory Surgical Centers, or ASC, or Office-Based Lab, OBL, depending on the local and state regulations applied to the care delivery. The definitions were taken directly from the Centers of Medicare and Medicaid Services, or CMS, which defined an ASC as a free-standing facility other than a physician's office where diagnostic and surgical services are provided on an ambulatory basis, whereas an Office-Based Lab is a location where the health professional routinely provides examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. If there is any doubt on how your facility identifies itself, the Registry would recommend internal clarifications from colleagues to support coding. For all insurance matters, the Registry will defer to how your facility identifies insurance plans. Please check with your billing department and select all sources that apply in Sequence 310, Payment Source. If the patient uses Medicare as a payment source, the Centers for Medicare and Medicaid Services, or CMS, has removed Social Security number-based health insurance claim numbers from Medicare cards, and they are now using Medicare Beneficiary Identifiers, or MBIs, for Medicare transactions like billing, eligibility status, and claim status. MBIs are clearly different than the HICN in that they are 11 characters in length and made up of only numbers and uppercase letters, no special characters. If you use lowercase letters, our system will convert them to uppercase letters. For more information regarding CMS and its policies or practices, please reach out to them directly as we are unable to speak on behalf of CMS. At this point in data entry in the ACC data collection tool, each site identifies the pathway it needs to go down based on the procedures being performed during the episode of care. Episode of care is best described as time between arrival at your facility through discharge. Currently, our participating sites can capture four pathways, including diagnostic coronary angiography only, or PCI, with or without coronary angiography, or implantable cardiac defibrillator, or permanent pacemaker. Before we get into the details of each pathway, we must first educate how our beta launch expects our participants to code this data element. If you notice, the coding instructions ask the site to indicate all procedures. Additionally, the data collection tool will allow for multiple selections. The reason for this is to accommodate newer cardiovascular procedures being performed in the outpatient setting and to accommodate multiple procedures being performed during the same lab visit and or episode of care. However, constraints were applied internally as the expectation set during beta launch was that the registry is only going to focus on one procedure during the lab visit and episode of care. Simply said, this is currently functioning as a single select field. If multiple selections are chosen, an error will trigger, forcing the site to go back and identify the single procedure being performed. First up is the diagnostic coronary angiography only pathway. If a patient has a diagnostic coronary angiography only procedure, which is the passage of a catheter into the aortic root or other great vessel for the purpose of angiography of the native or bypass grafts as their only procedure during the episode of care, then this is the most appropriate selection. If the patient undergoes the placement of an angioplasty guidewire, balloon, or other device such as stent, atherectomy, brachytherapy, or thrombectomy catheter into a native or bypass graft for the purpose of mechanical coronary revascularization with or without coronary angiography during the episode of care, then PCI with or without coronary angiography is the most appropriate selection. If the patient undergoes the placement of a device that detects a life-threatening rapid heartbeat, and if it occurs, the device quickly sends an electrical shock to the heart in hopes to restore normal rhythm during the episode of care, then implantable cardiac defibrillator is the most appropriate selection. And lastly, if the patient undergoes the placement of an electronic device to monitor heart rate and rhythm and give the heart electrical stimulation when it does not beat normally during the episode of care, then permanent pacemaker is the most appropriate selection. Each cardiovascular ASC procedure pathway is assigned unique and specific condition history data elements. The entire team, including ambulatory surgery centers and office-based lab stakeholders, thoughtfully and concisely appointed these patient conditions to the respective pathway based on reporting needs and keeping in mind the need for a lean data set. So while the data dictionary lists every possible condition history that could be used within the entire CV ASC registry, constraints are applied in the backend to only allow certain conditions to appear in the specific pathway chosen when using the data collection tool. Thus, the easiest means to know which conditions are captured for a single procedure is the data collection form. To code yes in sequence 15510, Condition History Occurrence, there must be a clinical diagnosis of the indicated medical condition, and the data dictionary does provide education on what the medical condition is if our users are unfamiliar. All pathways have child fields that seek more information when a documented clinical diagnosis is captured in the patient's history, which we will review in depth in upcoming slides. For the permanent pacemaker pathway, sequence 4400, Atrial Fibrillation Classification, will populate when a history of atrial fibrillation is captured. If a patient has been diagnosed with a history of atrial fibrillation, then more information is requested to depict its classification, but even more specifically, the most recent classification. Sequence 4225, Most Recent Cardiac Arrest Date, and sequence 4240, Bradycardia Arrest, will populate when a history of a prior cardiac arrest is captured. Sequence 4225, Most Recent Cardiac Arrest Date, is indicating the date of the patient's most recent cardiac arrest. When only the year is known, please code 0101 and insert the known year. However, if the specific year is unknown, the year may be estimated based on timeframes found in prior documentation. For example, if the patient had documentation of most recent cardiac arrest documented in a medical record from 2011, then the year 2011 would be used and sequence 4225 would be coded as 01-01-2011. After indicating the patient had a prior cardiac arrest, sequence 4240, Bradycardia Arrest, wants to know if the patient had a cardiac arrest that was the result of bradycardia. If this type of documentation is not present, then physician clarification is warranted. Otherwise, no would be coded. Sequence 4010, New York Heart Association Functional Classification, will populate when a history of heart failure is captured. When the patient has been diagnosed with heart failure, the registry wants to know the patient's New York Heart Association Functional Classification based on physician documentation at the time of the current procedure. The NYHA Functional Classification must be specifically documented in the medical record as it cannot be left for interpretation by the abstractor based upon patient symptoms. Sequences range from the least limiting, or class 1, to the most limiting, or class 4. Sequence 4295, Most Recent MI Date, will populate when a history of myocardial infarction is captured. If the patient has a history of myocardial infarction, the registry wants to know the most recent date prior to the procedure. This data element may look like the one used in the CAT-PCI pathway, however, it has an additional note. When the patient has a history of an old or remote MI documented in the medical record by the clinician and a timeframe is unable to be determined from prior medical records or by clarifying with the clinician, the MI can be coded as having occurred 5 years ago. All pathways capture the date of the patient's most recent procedure that occurred prior to arrival at your facility. If the month or day of the most recent procedure is unknown, please code 0101 and insert that known year, but if the year is unknown, it may be estimated based on timeframes found in the medical record. For example, if the patient had the verbiage of most recent procedure, insert whatever the procedure may be, documented in a record from 2011, then the year, in this case 2011, can be used to support coding and 0101-2011 would be captured. Sequence 4150, Prior Left Ventricular Ejection Fraction Assessed, is indicating if a left ejection fraction percentage has been assessed in the last 12 months prior to the start of the procedure. This is coded for all device types. If a diagnostic test is not available in the medical record, then a stated LVEF measurement can be used if there is a date affiliated with it to confirm it was performed in the last 12 months. If a date is not affiliated with the LVEF measurement, it cannot be used for coding as it is not certain the target value would be met in those scenarios. Sequence 4155, Most Recent LVEF Date, is indicating the date the most recent left ventricular ejection fraction was assessed as documented by a physician or noted on diagnostic testing in the last 12 months prior to the start of the procedure. If only the year is known, then please code 0101 and insert that known year. If the specific year is unknown in the current record, the year may be estimated based on timeframes found in prior medical record documentation. For example, if the patient had Most Recent LVEF documented in a record from 2011, then the year 2011 can be utilized and coded as 01-01-2011. Sequence 4160, Most Recent LVEF Percent, is indicating the left ventricular ejection fraction cited by the implanting physician as the indication for the ICD in the last 12 months prior to the start of the procedure. In the absence of a physician-cited LVEF, indicate the most recent LVEF that was assessed via any means, so LV gram, echo, MRI, CT, or nuclear testing. This is going to be entered as a percentage in the range of 1-99. If a percentage range is reported, you're going to code the lowest number of that range. So if the provider documents that the most recent LVEF is 50-55%, you're going to code 50 as that's the lowest. An LVEF measurement that is reported as less than or greater than will be coded to the nearest whole number. So if there is documentation that says the LVEF is less than 40, then 39 would be coded, and vice versa. If it's greater than 40, then 41% would be coded. When a numeric value is not associated with the ejection fraction, then the clinician must be consulted and the numeric value documented in the medical record in order to code. Sequence 6030, pre-procedure hemoglobin, is capturing the last or most recent lab or point of care hemoglobin value 30 days prior to the start of the current procedure. This element can be captured up to the hundredth place, or two places after the decimal. However, if you have a hemoglobin that reports to the thousandth place, or three places after the decimal, then simply truncate or drop that value. As an example, if the level is reported as 10.328 grams per deciliter, then you would code 10.32 and simply drop the 8. Lastly, if a hemoglobin level was not drawn to meet the target value, select sequence 6031 hemoglobin not drawn. Sequence 6025, pre-procedure blood urea nitrogen, or BUN, is capturing the last or most recent lab or point of care value between 30 days prior to the start of the procedure. This element is captured as a whole number. However, if you have a value that reports to a decimal, then please truncate or simply drop the decimal values. As an example, if the level is reported as 13.32 milligrams per deciliter, then code 13 and drop the 0.32. Lastly, if a blood urea nitrogen level was not drawn to meet the target value, then you would select sequence 6026 blood urea nitrogen not drawn. Sequence 6035 pre-procedure sodium is capturing the last or most recent lab or point of care value between 30 days prior to the start of the current procedure. This element is captured as a whole number. However, if you have a value that reports to a decimal value, simply truncate or drop the decimal values. As an example, if the level is reported as 125.32 milliequivalents per liter, then you would code 125 and drop the 0.32. Lastly, if a sodium level was not drawn to meet the target value, then you would select sequence 6036 sodium not drawn. Sequence 15694 procedure room entry date and time is indicating the date and time the patient entered the procedure room. Sequence 7000 procedure start time is indicating the date and time the procedure started to the nearest minute. The start time of the procedure is the time that the skin incision vascular access or its equivalent was made to start the procedure. Sequence 7005 procedure end date and time is indicating the ending date and time at which the operator breaks scrub at the end of the procedure. If more than one operator is involved in the case, then use the date and time the last operator breaks scrub for the last time. When this information is not documented, please code the time the patient left the procedure room. However, the expectation is that sites will work with their colleagues to obtain scrub break time as this will more accurately reflect throughput at the procedural level and assure consistency and data capture across the registry. Sequence 15695 procedure room exit date and time is indicating the date and time the patient exits or leaves the procedure room.

sequence numbers

CVASC registry

permanent pacemakers

patient arrival times

procedure pathways

patient conditions