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 ICD portion of the CVASC registry. After participation in this learning activity, the learner should be able to identify, discuss, and explore the sequence numbered elements in the ICD 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. The CTA 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 freestanding 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 guide wire, 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. Sequence 4400, Atrial Fibrillation Classification, and Sequence 4405, Plans for Cardioversion of Atrial Fibrillation, 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. The data dictionary provides guidelines and definitions to help determine the best selection based on the individual patient. This should be documented by the implanting physician, as it is a clinician's responsibility and cannot be made by the abstractor. When the documentation is not clear, then we would ask you to clarify. For your information and knowledge, we will go over the definitions. Paroxysmal is defined as atrial fibrillation that terminates spontaneously or with intervention within seven days of onset. Episodes may recur with variable frequency. Permanent is defined as continuous atrial fibrillation that has sustained seven days or more or with electrical or pharmacological termination. Long-standing persistent is defined as continuous atrial fibrillation of more than 12 months duration. And finally, permanent is a term used when the patient and the clinician make a joint decision to stop further attempts to restore and or maintain sinus rhythm. Acceptance of atrial fibrillation represents a therapeutic attitude on the part of the patient and clinician rather than an inherent pathophysiological attribute of the atrial fibrillation. Acceptance of AFib may change as symptoms, the efficacy of therapeutic interventions, and patient and clinician preferences evolve. Additionally, if a patient has been diagnosed with a history of atrial fibrillation, then the registry wants to know if there is a planned cardioversion for their atrial fibrillation. For your knowledge, a cardioversion is a procedure that uses the synchronized shocks or intravenous medications to convert the rhythm to a sinus rhythm. The notes further assist the abstractor in certain scenarios. For instance, sites would code no for a history of a cardioversion. But on the other hand, sites would code yes if the patient was in atrial fibrillation and cardioverted prior to the start of the generator implant procedure for this admission. And sites would also code yes if the patient is scheduled for a cardioversion. Sequence 4.2.25 most recent cardiac arrest date, sequence 42.40 bradycardia arrest, sequence 42.35 v-fib arrest, and sequence 42.30 v-tac arrest will populate when a history of a prior cardiac arrest is captured. Sequence 42.25 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 record from 2011, then the year 2011 would be used and sequence 42.25 would be coded as 01-01-2011. After indicating the patient had a prior cardiac arrest, sequence 42.40 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. After indicating the patient had a prior cardiac arrest, sequence 42.35 v-fib arrest wants to know if the patient had a cardiac arrest that was the result of ventricle fibrillation as reflected in the documentation. If this type of documentation is not present, then physician clarification is warranted. Otherwise, no would be coded. For your knowledge, v-fib arrest is defined as rapid, usually occurring more than 300 beats per minute, grossly irregular ventricular rhythm with marked variability in QRS cycle length, morphology, and amplitude. After indicating that the patient had a prior cardiac arrest, sequence 42.30 v-tach arrest wants to know if the patient had a cardiac arrest that was the result of ventricular tachycardia. If this type of documentation is not present, then physician clarification is warranted. Otherwise, no would be coded. The supporting definition further defines ventricular tachycardia as a cardiac arrhythmia of three or more consecutive complexes in duration emanating from the ventricles at a rate of 100 beats per minute. Sequence 4190 ischemic cardiomyopathy time frame and sequence 4195 ischemic cardiomyopathy guideline directed medical therapy maximum dose will populate when a history of ischemic cardiomyopathy is captured. After indicating that the patient has a history of ischemic cardiomyopathy sequence 4190 ischemic cardiomyopathy time frame is asking essentially how long has it been since they were initially diagnosed whether it was less than three months or three months or more. If this type of documentation is not present then physician clarification is warranted otherwise this data element would be left blank. In sequence 4195 ischemic cardiomyopathy guideline directed medical therapy maximum dose the registry wants to know if the patient with ischemic cardiomyopathy has been on guideline directed medical therapy for at least three months. Please make note that this type of documentation is the responsibility of the clinician and cannot be determined by the abstractor based on a list of medications. This type of therapy is individualized but typically should include some combination of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker and beta blocker therapy which are adjusted to target doses as tolerated. In other patients diuretics may be needed or adjusted to control fluid retention and even in other cases patients may need aldosterone antagonists hydrolazine and nitrates. Patients who are going to receive substantial benefit from medical treatment alone usually show some clinical improvement during the first three to six months. Medical therapy is also assumed to include adequate rate control for tachyarrhythmias such as atrial fibrillation. Therefore it is recommended that guideline directed medical therapy be provided for at least three months before any planned reassessment of LV function to consider device implantation. Acceptable documentation includes guideline directed medical therapy, maximum, optimum, appropriate dose, medical therapy or medical management for cardiomyopathy as well as a discussion in the medical record regarding medications as it relates to the patient's cardiomyopathy. It is acceptable for documenting guideline medical therapy. Other acceptable statements include good neurohormonal therapy, managed appropriately on heart failure medications, failed medical management of heart failure and so on. Please work with your clinicians to determine a process of documentation that will allow for the coding of this element for all generator procedures. A statement regarding maximum guideline directed medical therapy for three months or more should be considered as something to be incorporated as a smart phrase within the facility's electronic health record environment. The selections for coding sequence 4195 ischemic cardiomyopathy guideline directed medical therapy maximum dose include yes for three months, not documented, not attempted and the inability to complete. If the patient has been on guideline directed medical therapy maximum dosing for at least three months then yes for three months would be coded. If there is no documentation of guideline directed medical therapy maximum dosing then not documented would be selected. If guideline directed medical therapy was not attempted on the patient then not attempted would be selected. In scenarios where the patient was unable to continue their guideline directed medical therapy for three months or where the patient is on guideline directed medical therapy but it has been less than three months then inability to complete would be selected. Without a definitive time frame documented or the ability to determine the time frame from the medical record inability to complete would be appropriate. This selection would also include patients started on guideline directed medical therapy but it has been less than three months due to patient refusal maybe an allergy or an absolute contraindication. After indicating that that the patient has a history of non-ischemic cardiomyopathy sequence 4205 non-ischemic cardiomyopathy time frame is asking essentially how long has it been since they were initially diagnosed whether it was less than three months or three months or more. If this type of documentation is not present then physician clarification is warranted otherwise this data element would be left blank. If guideline directed medical therapy was not attempted on the patient then not attempted would be selected. In sequence 4210 non-ischemic cardiomyopathy guideline directed medical therapy maximum dose the registry wants to know if the patient with it with non-ischemic cardiomyopathy has been on guideline directed medical therapy for at least three months. Please make note that this type of documentation is the responsibility of the clinician and cannot be determined by the abstractor based on a list of medications. This type of therapy is individualized but typically should include some combination of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker and beta blocker therapy which are adjusted to target doses as tolerated. In certain patients diuretics may be needed or adjusted to control fluid retention and even in other cases patients may need aldosterone antagonists hydrolazine and nitrates. Patients who are going to receive substantial benefit from medical treatment alone usually show some clinical improvement during the first three to six months. Medical therapy is also assumed to include adequate rate control for tachyarrhythmias such as atrial fibrillation therefore it is recommended that guideline directed medical therapy be provided for at least three months before any planned reassessment of LV function to consider device implantation. Acceptable documentation includes guideline directed medical therapy, maximum, optimum, appropriate dose, medical therapy or medical management for cardiomyopathy. As well a discussion in the medical record regarding medications as it relates to the patient's cardiomyopathy is acceptable for documenting guideline directed medical therapy. Other acceptable statements include good neurohormonal therapy managed appropriately on heart failure medications, failed medical management of heart failure and so on. Please work with your clinicians to determine a process of documentation that will allow for the coding of this element for all generator procedures. A statement regarding maximum guideline directed medical therapy for three months or more should be considered as something to be incorporated as a smart phrase within the facility's electronic record environment. The selections for coding sequence 4210 non- ischemic cardiomyopathy guideline directed medical therapy maximum dose include yes for three months, not documented, not attempted, and inability to complete. If the patient has been on guideline directed medical therapy maximum dosing for more than three months, they should be able to complete the therapy maximum dosing for at least three months, then yes for three months would be coded. If there is no documentation of guideline directed medical therapy maximum dosing, then not documented would be selected. Sequence 4205 non- ischemic cardiomyopathy time frame and sequence 4210 non- ischemic cardiomyopathy guideline directed medical therapy maximum dose will populate when a history of non- ischemic cardiomyopathy is captured. In scenarios where the patient was unable to continue their guideline directed medical therapy maximum dosing for three months or where the patient is on guideline directed medical therapy but it has been less than three months, then inability to complete would be selected. Without a definitive time frame documented or the ability to determine the time frame from the medical record, inability to complete would be the appropriate selection. This selection would also include patients started on guideline directed medical therapy but it has been less than three months due to patient refusal, an allergy, or an absolute contraindication. Sequence 4010 New York Heart Association functional classification will populate when a history of heart failure is captured. When a 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 and cannot be left for interpretation by the abstractor based upon patient symptoms. Classifications range from the least limiting or class one to the most limiting or class four. Sequence 4295 most recent MI date will populate when a history of myocardial infarction is captured. If the patient has a history of a 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 cath 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 the time frame is unable to be determined from prior records or by clarifying with the physician, the MI can be coded as having occurred five years ago. Sequence 4545 structural abnormality type will populate when a history of structural abnormalities are captured. If the patient has a history of a structural abnormality, sequence 4545 seeks to capture the type or types. This is a multi-select field, therefore, If the patient has a history of a left ventricular aneurysm, left ventricular non-compaction syndrome that puts the patient at risk for setting cardiac arrest, and tacosubaric aneurysm, sequence 4545 seeks to capture the type or types. This is a multi-select field, therefore, if the patient has had multiple structural abnormalities from birth to the current procedure, If the patient has a history of hypertrophic cardiomyopathy with high risk features, of which include ventricular fibrillation, cardiac arrest, spontaneous sustained ventricular tachycardia, a family history of premature sudden death, unexplained syncope, left ventricular thickness of 30 millimeters or thicker, abnormal exercise blood pressure, non-sustained spontaneous ventricular tachycardia, atrial fibrillation, myocardial ischemia, left ventricular outflow obstruction, high risk mutation, or intense competitive physical exertion, then hypertrophic cardiomyopathy with high risk features would be selected. If a high risk feature is not present in the documentation, then hypertrophic cardiomyopathy with high risk features would not be selected. Infiltrated structural abnormalities would be captured if there is documentation of amyloidosis, sarcoidosis, giant cell myocarditis, or Chagas disease. This list is not all-inclusive of all potential infiltrative structural abnormalities. Therefore, please work with your clinician to assure the appropriate coding of other infiltrative abnormalities. While the selection of arrhythmogenic ventricular cardiomyopathy references the right ventricle, both right and left arrhythmogenic ventricular cardiomyopathies are captured when a diagnosis is made. Congenital heart disease associated with sudden cardiac arrest can include tetralogy of fallot, ventricular septal defects, Epstein abnormality, transposition of great vessels, a patent foramen ovale, atrial septal defect, and a common ventricle. This list is not all-inclusive of all potential congenital heart diseases associated with sudden cardiac arrest structural abnormalities. Therefore, please work with your clinician to assure the appropriate coding of others.

CVASC Registry

documentation

cardiovascular procedures

cardiac arrest

heart failure

myocardial infarction

coding instructions