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 PCI 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 PCI 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 CA 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 MVIs, for Medicare transactions like billing, eligibility status, and claim status. MVIs 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. Sequence 6000 height is capturing a patient's documented height in centimeters to the hundredth value prior to the start of the procedure. Start of procedure time is equivalent to what is coded in sequence 7000 procedure start date and time. Sequence 6005 weight is capturing the patient's documented weight in kilograms to the hundredth value prior to the start of the procedure. Start of procedure is equivalent to the time coded in sequence 7000 procedure start date and time. Sequence 4625 tobacco use is indicating the frequency a patient uses tobacco as assessed and documented on arrival to your facility for their diagnostic coronary angiography or PCI procedure. To emphasize, this data element is focused on tobacco, not nicotine. So nicotine delivery devices such as vaping and e-cigarettes are not considered in the coding of this data element. These definitions are aligned to industry standard definitions to support data capture directly from EMRs, electronic medical records, and to align with meaningful use. Therefore, it can be coded based on documentation of tobacco use, such as patient is a former smoker of cigars would be coded as former, or it can be coded based on descriptive documentation that meets the definition in the data dictionary. If coding using descriptive documentation, you would consider any tobacco product as an equivalent to cigarettes, which are referenced in the definitions. If no documentation is present and the current and prior smoking status is not known, unknown would be coded. 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. Both cath PCI pathways, which include diagnostic coronary angiography only or PCI with or without coronary angiography, want to know the date of the patient's most recent myocardial infarction that occurred prior to arrival at your facility. If the month or day of the most recent myocardial infarction is unknown, please use 0101 and insert the year. 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 myocardial infarction documented in a record from 2011, then the year, in this case 2011, can be used to support coding 01012011. Each cardiovascular ASC procedure pathway is assigned unique and specific procedure history data elements. The entire team, including ambulatory surgery center and office-based lab stakeholders, thoughtfully and concisely appointed these procedures to their respective pathway based on reporting needs and keeping in mind the need for lean datasets. So while the data dictionary lists all applicable procedures that could be used within the entire registry, constraints are applied in the back end to allow certain procedures to appear in the specific pathway when using the data collection tool. Thus, the easiest means to know which procedures are captured for a specific pathway is taking a look at the data collection form. To code yes in Sequence 15511, Procedure History Occurrence, there must be documentation the patient has undergone the indicated medical procedure. 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 4561, the Canadian Study of Health and Aging Clinical Frailty Scale, is captured on both procedures of the CAHPCI pathway. It is capturing the current or most recent condition of the patient's physical condition observed prior to their CAHPCI procedure. Any descriptive documentation found in the medical record by any clinician that meets the definition is satisfactory. So if it's documented in the medical record, if the patient reports they are normally active but now are unable to ambulate on arrival due to pain, then that would be enough to code vulnerable. Or if there's physician documentation of a specific frailty scale, that will support coding. So if the physician says the patient is vulnerable, that will satisfy the definition to code vulnerable, assuming the physician is familiar with the scale. Sequence 4001, Heart Failure, seeks to capture if the patient has a documented diagnosis of heart failure. When there is no documentation of a diagnosis of prior heart failure to meet the target value of any occurrence between birth and current procedure, then no would be coded. Sequence 4011, New York Heart Association Classification, is capturing the patient's latest dyspnea, or functional class, coded as the New York Heart Association Classification, or NYHA, prior to the procedure. It must be specifically documented in the medical record and not coded by the abstractor based upon patient symptoms. Selections include class 1, which is the least restrictive, to class 4, which is the most restrictive. Sequence 4012, Heart Failure, Newly Diagnosed, is indicating if the patient's heart failure was newly diagnosed. The notes further clarifies to code yes if there is no documentation of a prior diagnosis of heart failure. Sequence 4013, Heart Failure Type, is indicating the patient's most recent type of heart failure as classified by the patient's left ventricular ejection fraction prior to the procedure. It can be coded based on physician diagnosis, such as HFREF would be coded as Heart Failure with Reduced Ejection Fraction, or on descriptive documentation that meets the definition in the data dictionary. Selections include Heart Failure with Reduced Ejection Fraction, or HFREF, which is also referred to as Systolic Heart Failure or Cardiomyopathy. This is heart failure in a patient with documented LVEF of 40% or less. Heart Failure with Preserved Ejection Fraction, HFPEF, is heart failure in a patient with documented LVEF of 50% or more. And lastly, Heart Failure with Mid-Range Ejection Fraction, HFMEF, is heart failure in a patient with documented LVEF of greater than 40 but less than 50. If the type of heart failure is unknown, then sequence 4014, Heart Failure Type Unknown, would be selected instead. Sequence 5037, Electrocardiac Assessment Method, is indicating the method used for electrocardiac assessment, whether it's abnormal, uninterpretable, or normal, 30 days prior to the procedure. The coding instructions are outlined in the notes. It is hierarchical and should be applied as follows. First, you want to capture the assessment method that identified the last abnormal electrocardiac value between 30 days prior to the procedure. If there was no abnormal electrocardiac value observed, then you're going to capture the assessment method performed that identified the last uninterpretable electrocardiac value 30 days prior to the procedure. And if an uninterpretable electrocardiac value was not observed, then you're going to capture the assessment method that identified the last normal electrocardiac value 30 days prior to the procedure. But if an electrocardiac assessment was not performed 30 days prior to the procedure, you would then code none. Sequence 5032, Electrocardiac Assessment Results, is indicating the results, whether they're abnormal, uninterpretable, or normal, of the electrocardiac assessment 30 days prior to the procedure. The coding instructions outlined in the notes are hierarchical and should be applied as follows. First, select abnormal if the assessment identifies a heart rate or rhythm that is abnormal and clinically relevant for the patient. The evidence of an abnormal rate or rhythm that is clinically significant may be overtly apparent, such as VTAC, VFib, symptomatic bradycardia, ST deviation of 5 millimeters or more to support coding. Or the evidence of an abnormal rate or rhythm that is clinically significant may only be apparent due to provider documentation, such as new onset AFib, exercise-induced VT, normal sinus rhythm with left ventricular hypertrophy, so on and so forth. When the abnormality is not overtly apparent or specifically documented by the provider, but it is recognized by the abstractor, we would ask that you would clarify with the physician if the rhythm is clinically significant for the patient. This is subjective and unique to the patient, and if the physician agrees the abnormality is clinically significant, please ensure there is documentation to support coding abnormal. But if there are no abnormal results you would then look to see if there were any uninterpretable results and this would be selected when there is specific documentation that a determination of normal versus abnormal of the heart's electrical activity could not be made. And if neither abnormal or uninterpretable results are noted you would select normal because none of the above apply. Sequence 5033 antiarrhythmic therapy initiated prior to cath lab is indicating if the patient received new antiarrhythmic therapy defined as initiation of a new drug to the patient for the purpose of controlling an abnormal rhythm in the last 30 days prior to the procedure. When a patient is experiencing an abnormal rhythm and a medication is given IV push or bolus such as ACLS drugs like atropine, lidocaine, adenosine so on so forth while they are treating the rhythm acutely they may not be controlling it for the long term and those type of medications would not be captured here. Sequence 5034 electrocardiac abnormality type is capturing all abnormal values 30 days prior to the procedure. Here you will select all abnormal electrocardiac findings that meet the definition and are supported by physician diagnosis. These are the selections for electrocardiac abnormality type. Each definition is available in the data dictionary and we encourage you to read through them and become familiar with the terminology. Please take a few moments if needed to read through this slide. Sequence 5200 stress test performed is indicating if a non-invasive stress test was performed between birth or previous procedure and current procedure. When the target value is separated into two distinct thoughts it is easier to apply to the patient scenario. When the patient presents for a new episode of care apply this portion of the target value the last value between birth and current PCI procedure. When the patient presents to the cath lab after having a diagnostic coronary angiogram and or PCI during the episode of care apply this portion of the target value the last value between previous procedure and current procedure. As most if not all patients are presenting from home to an ambulatory surgery center or office-based lab this portion of the target value will almost always be applied capturing a stress test performed any time between birth and the current procedure regardless of a history of a prior PCI or CABG. Sequence 5201 stress test performed is indicating the last type or most recent of non-invasive stress tests performed between birth and the current procedure. Selections include an exercise stress test without imaging which is a continuous ECG recording or monitoring test without additional imaging performed initially at rest and then during exercise or pharmacologic stress to detect the presence of coronary artery disease, abnormal heart rhythms, abnormal blood pressure response to exercise, or evaluate exercise tolerance and exercise related symptoms. A stress echocardiogram is a cardiac ultrasound procedure obtained at rest and during exercise or pharmacological stress. Stress imaging with CMR which is magnetic resonance imaging of the heart at rest and during exercise or during pharmacologic stress. And lastly a stress nuclear which is a nuclear stress test that measures blood flow to the heart at rest and during exercise or pharmacological stress by comparing the distribution throughout the heart of a radioactive dye injected into the bloodstream. Sequence 5204 most recent date of stress test is indicating the most recent date of the stress test performed between birth and the current procedure. When capturing historical data elements that require a date and only the year is known it is acceptable to code 0101 then insert that known year. If the year is unknown it is acceptable to use documentation from a recent medical record identifying that a stress test was performed. In other words if a medical documentation states stress test performed in a record from 2011 then it is acceptable to use that year to code and 0101 2011 would be coded. Sequence 5202 stress test result is indicating the results of the non-invasive stress test performed between birth and current procedure. While the data dictionary does provide guidance for coding stress test results should the information you are provided clearly and explicitly fall within the definition parameters would be acceptable to code. Additionally it is also acceptable to code based on physician documentation or interpretation as this reflects the outcome of the stress test experience. However as interpretation of stress test results requires licensing and training if there is uncertainty in the documentation supplied please clarify with the physician. If there is no opportunity to clarify and no documentation present to support coding unavailable would be coded. Sequence 5203 stress test risk extent of ischemia is indicating the risk or extent of ischemia for the non-invasive stress test performed between birth and the current procedure. While the data dictionary does provide guidance for coding stress test risk and extent of ischemia should the information you are provided clearly and explicitly fall within the definition parameters it would be acceptable to code. Additionally it is acceptable to code based on physician documentation or interpretation as this reflects the outcome of the stress test experience. However as interpretation of stress test results requires licensing and training if there is ever any uncertainty in the documentation supplied please clarify with the physician. If there is no opportunity to clarify and no documentation present to support coding unavailable would be coded. Sequence 5220 cardiac CTA performed is indicating if a cardiac computerized tomographic angiography was performed between birth or previous procedure and current procedure. When the target value is separated into two distinct thoughts it is easier to apply to the patient scenario. When the patient presents for a new episode of care apply this portion of the target value. Last value between birth and current procedure. When the patient presents to the lab after having a diagnostic or PCI procedure during the episode of care apply this portion of the target value. The last value between previous procedure and current procedure. As most patients are presenting from home to an ambulatory surgery center or office space lab this portion of the target value will almost always be applied capturing a cardiac CTA performed anytime between birth and the current procedure regardless of a history of PCI or CABG. Sequence 5226 cardiac CTA date is indicating the most recent date a cardiac computerized tomographic angiography or CTA was performed between birth and the current procedure. Sequence 5227 cardiac CTA results is indicating the most recent results of the cardiac CTA performed between birth and the current procedure. This is a multiple select field as more than one condition can be seen among all the coronary arteries and their branches. Obstructive CAD would be coded when there is greater than or equal to 50% luminal diameter narrowing of an epicardial artery or left mean stenosis. Non-obstructive CAD would be coded when there is less than 50% luminal diameter narrowing of an epicardial or left mean stenosis. Unclear severity would be coded when coronary artery disease severity is unclear or conflicting. Structural disease would be coded when there is an abnormality of the heart that is non-coronary meaning that it does not affect the blood vessels in the heart but rather involves the valves, walls, or chambers. No CAD would be coded when there is no evidence of coronary artery disease. If the results of the cardiac CTA are unknown sequence 5228 cardiac CTA results unknown would be selected instead. Sequence 5256 agastin calcium score assessed is indicating if the agastin coronary calcium score was assessed between birth or previous procedure and current procedure. When the target value is separated into two distinct thoughts it is easier to apply to the patient scenario. When the patient presents for a new episode of care apply this portion of the target value the last value between birth and current procedure. When the patient presents to the cath lab after having a diagnostic or PCI procedure during the episode of care apply this portion of the target value last value between previous procedure and current procedure. As most patients are presenting from home to an ambulatory surgery center or office based lab this portion of the target value will almost always be applied capturing an agastin calcium score performed any time between birth and the current procedure regardless of a history of a prior PCI or CABG. Sequence 5255 agastin calcium score is indicating the total agastin coronary calcium score between birth and the current procedure. After a coronary calcium scan a calcium score called an agastin score is provided. The score is based on the amount of calcium found in the coronary arteries. The test may get an agastin score for each major artery and a total score. Sequence 5257 agastin calcium score date is indicating the most recent date of the agastin calcium score obtained between birth and the current procedure. Sequence 5263 prior diagnostic coronary angiography procedure without intervention is indicating if the patient has a diet had a diagnostic coronary angiography procedure without a subsequent intervention. This data element seeks to identify when an intervention such as CABG or PCI was not the intended treatment after the diagnostic cath. The term procedure in the target value is in reference to the diagnostic only or PCI procedure and while this data element is shared with our hospital registries where multiple procedures may occur during one episode of care the ASC registry is initially built to handle one pathway per episode of care. Thus the target value for an ASC or OBL is better understood if written any occurrence between birth and current procedure. Sequence 5264 prior diagnostic coronary angiography procedure date is coded with the most recent date of the diagnostic cath performed prior to the current procedure. When only the year is known please code 0101 and insert that known year. If the specific year is unknown and in the record the year can be estimated based on timeframes found in prior documentation it may be used for coding. As an example if the patient had most recent diagnostic coronary angiography documented in a record from 2011 then the year 2011 can be utilized and coded as 0101 2011. Sequence 5265 cardiac CTA results is indicating the most recent results of the prior diagnostic coronary angiography performed between birth and the current procedure. This is a multiple select field as more than one condition can be seen among all the coronary arteries and their branches. Obstructive CAD would be coded when there is greater than or equal to 50% luminal diameter narrowing of an epicardial artery or left mean stenosis. Non-obstructive CAD would be coded when there is a less than 50% luminal diameter narrowing of an epicardial artery or left mean stenosis. Unclear severity would be coded when coronary artery disease severity is unclear or conflicting. Structural disease would be coded when there is an abnormality of the heart that is non-coronary meaning that it does not affect the blood vessels in the heart but rather involves the valves walls or chambers. No CAD would be coded when there is no evidence of coronary artery disease. If the results of the prior diagnostic coronary angiography are unknown then sequence 5266 prior diagnostic coronary angiography procedure results unknown would then be selected. Sequence 6991 pre-procedure medications administered captures medications that were prescribed or administered to the patient within two weeks prior to and up to the start of the current procedure. The start of the current procedure is defined as what the date and time that is coded in sequence 7000 procedure start date and time. All medications the patient was prescribed prior to arrival regardless of the patient's compliance as well as medications the patient received at your facility prior to the cath lab procedure should be captured. The notes of the coding instructions clarify to code no if a patient was given a sublingual intravenous or short-acting formula of one of these medications. As well sites should code yes if the patient received an oral long-acting formula of the medication after admission but prior to the start of the procedure. Provider documentation of a medical reason as to why a medication was not prescribed supports coding contraindicated in sequence 6991. Exception in scenarios where a pre-procedure medication is ordered or prescribed in the ASC or OBL however due to system reasons it was not administered to the patient no would be coded for that medication. Sequence 6050 pre-procedure creatinine is capturing the last or most recent lab or point-of-care creatinine value between 30 days prior to the start of the current procedure. This element can be captured up to the hundredth place or two decimal two places after the decimal however if you have a creatinine that reports to the thousandth place or three places after the decimal then please truncate or simply drop that value. As an example if the level is reported as 1.328 milligrams per deciliter then code 1.32 milligrams per deciliter dropping that 8. Lastly if a creatinine level was not drawn to meet the target value then you would select sequence 6051 creatinine not drawn. 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 6100 pre-procedure total cholesterol 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 cholesterol that reports to a decimal value then please truncate or drop those values. As an example if the level is reported as 280.32 milligrams per deciliter then code 280 drop the 0.32. Lastly if a total cholesterol level was not drawn to meet the target value then you would select sequence 6101 total cholesterol not drawn. Sequence 6105 pre-procedure high-density lipoprotein or HDL 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 an HDL that reports to a decimal value then please truncate or simply drop the decimal values. As an example if the level is reported as 90.32 milligrams per deciliter code 90 dropping the 0.32. Lastly if a high-density lipoprotein level was not drawn to meet the target value then you would select 6106 high-density lipoprotein not drawn.

CVASC Registry Education

Sequence numbers in PCI

Arrival Date and Time

CA Classification Type

Payment Source

Data entry accuracy

Patient information capture

Diagnostic coronary angiography