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 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 in 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 15607, Procedure Type, is indicating all procedures that were performed between start of procedure and end of procedure. The ASC registry was initially built to handle one pathway per episode of care. Thus, while this is a select-all field, the only selections that can be selected together during one lab visit are diagnostic coronary angiography and percutaneous coronary intervention. All others are mutually exclusive of one another. When the passage of a catheter into the aortic root or other great vessels for the purpose of angiography of the native coronary arteries or bypass grafts supplying native coronary arteries occurs during the lab visit, diagnostic coronary angiography is the appropriate selection. When there is placement of an angioplasty guide wire, balloon, or other device such as a stent, atherectomy, brachytherapy, or thrombectomy catheter into a native coronary artery or coronary artery bypass graft for the purpose of mechanical coronary revascularization during the lab visit, percutaneous coronary intervention is the appropriate selection. To go back and emphasize, as soon as an angioplasty guide wire is inserted into the body, PCI performed or attempted is the appropriate selection. When the patient already has a device and is receiving a generator that is an upgrade or a change from one that was previously implanted, generator change is the appropriate selection. To provide some context to the definition, we have provided some procedural examples. When the patient already has a non-novel permanent pacemaker and is undergoing implantation of a novel pacemaker, which includes a CRTP, a leafless pacemaker, or a HIS left bundle pacemaker, then generator change would be selected. When the patient already has an ICD-CRTD and is undergoing implantation of another ICD-CRTD, then generator change would be selective. When the patient already has a novel permanent pacemaker and is undergoing implantation of another novel permanent pacemaker, which include CRTP, leafless pacemaker, or HIS left bundle pacemaker, then generator change would be selected. To review inclusion criteria, the ASC Registry is currently accepting data for novel pacemaker procedures. Novel pacemakers include the CRTP, the leafless pacemaker, or the HIS left bundle pacemaker. When the patient already has a device and is having the generator removed without re-implant of another generator during the current procedure, generator explant is the appropriate selection. To provide some context to the definition, we have provided some procedural examples. When the patient has a novel permanent pacemaker, which includes the CRTP, the leafless pacemaker, or the HIS left bundle pacemaker, and is undergoing implantation of a non-novel pacemaker, then generator explant would be selected. When the patient has an ICD-CRTD and is undergoing implantation of a non-novel permanent pacemaker, then generator explant would be selected. When the patient has a novel permanent pacemaker, ICD, or CRTD, and is undergoing explantation with no re-implantation of a device, generator explant would be selected. When the patient is receiving a permanent pacemaker or ICD-CRTD device for the first time during the current procedure, initial generator implant is the appropriate selection. To provide some context to the definition, we have provided some procedural examples. When the patient is undergoing implantation of their first novel permanent pacemaker, which includes the CRTP, the leafless pacemaker, or the HIS left bundle pacemaker, initial generator implant would be selected. When the patient is undergoing implantation of their first ICD-CRTD, then initial generator implant would be selected. When the patient has an ICD or CRTD and is undergoing implantation of a novel permanent pacemaker, then initial generator implant would be selected. When the patient has any prior permanent pacemaker and is undergoing implantation of their first ICD-CRTD, initial generator implant would be selected. When the passage of a catheter into the left ventricle for the purposes of angiography, such as an LVGRAM, or measurement of ventricular pressures and or oxygen saturation takes place, yes would be coded for sequence 7060, diagnostic left heart cath, if it occurred between start of procedure and prior to any intervention to meet the target value. If the left ventricular was only assessed post-intervention, in other words, post-PCI, then no would be coded. Segment 7061, LVEF percent, diagnostic left heart cath, captures the best estimate of the current left ventricular ejection fraction meeting the target value of start of procedure and prior to the PCI intervention. Please enter a percentage in the range of 1 to 99. If a percentage range is reported, it would report the lowest number of the range. For example, if it was 50 to 55 percent ejection fraction, 50 would be coded. If only a descriptive value is reported, enter the corresponding percentage value from the list below. Normal would be coded as 60 percent, good function would be coded as 50 percent, mildly reduced 45, fair function 40, moderately reduced 30 percent, poor function 25 percent, and severely reduced 20 percent. If the left ventricular ejection fraction was not assessed or not measured to meet the target value, then select 13306, left ventricular ejection fraction not assessed. Sequence 7065, concomitant procedures performed, is indicating if another procedure was attempted or performed in conjunction with the diagnostic coronary angiography and or PCI procedure. Sequence 7066, concomitant procedures performed type, is indicating the type or types of procedures attempted or performed in conjunction with the diagnostic coronary angiography and or PCI procedure. Please note, the procedures collected in the ASC registry are controlled by a procedure master list file that is maintained by the NCDR. If additional procedures need added for capture, the NCDR will update the master file. For ACC data collection tool users, these updates occur automatically. For third-party vendor tool users, the list is made available for downloading and uploading into the application from the ASC registry website under resources with the label technology downloads. Sequence 7320, arterial access site, is indicating the last location of percutaneous injury for the procedure. Sequence 7325, arterial crossover, is indicating if the procedure involved a crossover to a different access site. The note section clarified to code yes when the final procedure access site is subsequent to where arterial access for the procedure was first attempted. Sequence 6016, systolic blood pressure, is indicating the first systolic blood pressure in millimeters of mercury on the current procedure. The note section instructs to code the first non-invasive systolic blood pressure obtained in the cath lab procedure room. Sequence 7331, arterial access closure method, is indicating the arterial closure methods used in chronological order regardless of whether they provided hemostasis or not between start of the procedure and discharge. The term procedure in the target value is in reference to the cath 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 is better understood if written all values between start of procedure and discharge. The same closure method may be repeated. The notes further clarify that if multiple access sites were utilized during the procedure, only provide those closure methods used for the site identified in sequence 7320, arterial access site. The closure method devices that should be collected in your application are controlled by a closure method device master file. This file is maintained by the NCDR. If additional closure devices are needed, please notify us using the device request page within the ASC registry website under resources with the label technology downloads. Once closure devices are added for capture, the NCDR will update the master file. For the ACC data collection tool users, these updates occur automatically. For third party vendor tool users, the list is made available for downloading and uploading into the application from the ASC registry website under resources with the label technology downloads. The 7214 fluoroscopy time is indicating the total fluoroscopy time recorded to the nearest minute. Between start of the procedure as coded in sequence 7000, procedure start date and time, to the end of the CAF PCI procedure as coded in sequence 7005, procedure end date and time. The time recorded should include the total time for the lab visit. This element can be captured up to the 10th place or one place after the decimal. However, if you have a total fluoroscopy time that reports to the 100th place or two places after the decimal, then please truncate or simply drop the value. As an example, if the level is reported as 50.32 minutes, then code 50.3 and simply drop the two. Sequence 7215, contrast volume, is indicating the volume of contrast, whether it's ionic or non-ionic or both, used in milliliters between the start of the cath PCI procedure as coded in sequence 7000, procedure start date and time to the end of the cath PCI procedure as coded in sequence 7005, procedure ending time. The volume should be recorded to the total volume to reflect the total volume for the lab visit. This element is captured as a whole number. However, if you have a contrast volume that reports to the 10th place or one or more place after the decimal, then please truncate or drop the decimal values. As an example, if the level is reported as 50.3 milliliters, then code 50 and simply drop the three. Sequence 7210, cumulative air karma, is indicating the total radiation dose recorded to the nearest milligray or gray between start of the PCI cath PCI procedure as coded in sequence 7000, procedure start date and time to the end of the cath PCI procedure as coded in sequence 7005, procedure ending time. The value recorded should include the total dose of the lab visit. Cumulative air karma is the total air karma accrued from the beginning of an examination or procedure and includes all contributions from fluoroscopic and radiographic irradiation. This element is captured as a whole number. However, if you have a cumulative air karma that reports to a decimal value, then please truncate or drop the decimal values. As an example, if the level is reported as 50.3 milligray, then code 50 milligray and simply drop the three. Sequence 14278, dose area product, is indicating the total fluoroscopy dose to the nearest integer between the start of the cath PCI procedure as coded in sequence 7000, procedure start date and time to the end of the cath PCI procedure as coded in sequence 7005, procedure end date and time. The value recorded should include the total dose for the lab visit. This element is captured as a whole number. However, if you have a dose area product that reports to a decimal value, then please truncate or drop the decimal values. As an example, if the level is reported as 5000.3 milligrays per centimeter squared, then code 5000 and simply drop the three. Sequence 7400, indications for cath lab visit, is capturing patient symptoms or conditions prompting the cath lab visit for which the patient presented. It is not coded on what is learned during or after the procedure. The intent is that the user will select all pertinent indications prompting this patient coming for a cath lab visit. This can be coded on physician diagnosis and or any documentation found in the medical record meeting the data definition of each selection. There are no automatic or implied indications. Each definition should be carefully reviewed to ensure it accurately represents the patient condition and answering the question of why is this patient presenting for a cath procedure. Each definition will be carefully reviewed to ensure sites accurately represent the patient condition. New onset angina in two months or less would be selected if the patient presents for the cath lab procedure with new onset, which is defined as the patient never ever ever experienced angina in their lifetime of typical or atypical angina within two months of cath lab presentation. These patients must not have a history of prior MI, PCI, or CABG as these are understood by the registry to identify the patient has a history of cardiac ischemia equivalent to angina. Typical angina can be diagnosed by the physician or described by the patient but must meet all three of the characteristics of angina also known as definite to include one substernal chest discomfort with a characteristic quality and duration that is two provoked by exertion or emotional stress and three relieved by rest or nitroglycerin. Atypical angina can be diagnosed by the physician or described by the patient to meet two of the three characteristics of typical angina. This is also known as probable. Worsening angina would be selected if the patient presents for the cath lab procedure with a history of angina that has increased in severity or frequency within two months of cath lab presentation. These patients may have a history of prior MI, PCI, or CABG as these are understood by the registry to identify the patient has a history of cardiac ischemia equivalent to angina. Typical angina can be diagnosed by the physician or described by the patient but must meet all three characteristics of angina also known as definite. They must have substernal chest discomfort with a characteristic quality and duration that is two provoked by exertion or emotional stress and three relieved by rest or nitroglycerin. Atypical angina can be diagnosed by the physician or described by the patient to meet two of the three characteristics of typical angina. Atypical angina is also known as probable. Stable known CAD would be selected if the patient presents for the cath procedure in stable condition meaning without signs or symptoms of acute coronary syndrome, new onset, or worsening angina, or hemodynamic instability and has known coronary artery disease of 50% or worse in at least one vessel. This would be inclusive of patients with a history of interventions such as CABG or PCI or newly identified CAD meeting the definition. The patient may or may not be experiencing angina but if so then the angina must be stable without any any change in frequency or pattern for six weeks prior to the cath lab presentation. Suspected CAD would be selected if the patient presents for the cath procedure for suspected coronary artery disease meaning there is no prior documentation of CAD of 50% or worse in any vessel. Valvular disease would be selected if the patient's symptoms or conditions prompting the cath lab visit for which the patient presented is due to disease of at least one heart valve. This would be captured for a patient being evaluated for a transcatheter valve procedure such as transthoracic aortic valve repair or replacement or a mitral repair or replacement etc. Pericardial disease would be selected if the patient's symptoms or conditions prompting the cath lab visit for which the patient presented is due to pericardial disease which is the inflammation of the pericardial sac. Cardiac arrhythmia would be selected if the patient's symptoms or conditions prompting the cath lab visit for which the patient presented is due to a cardiac arrhythmia also known as a cardiac dysrhythmia or irregular heartbeat which is a group of conditions in which the heartbeat is irregular either too fast or too slow. Cardiomyopathy would be selected if the patient's symptoms or conditions prompting the cath lab visit for which the patient presented is due to cardiomyopathy which is disease of the heart muscle. Types of cardiomyopathy include hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular dysplasia, and tachosubose cardiomyopathy. LV dysfunction would be selected if the patient's symptoms or conditions prompting the cath lab visit for which the patient presented is due to left ventricular dysfunction. In left-sided or left ventricular heart failure, the left side of the heart must work harder to pump the same amount of blood. The two types of LV dysfunction are systolic which is a reduced adjustment fraction or HFREF and diastolic which is a preserved ejection fraction or HFPREF heart failure. Syncope would be selected if the patient's symptoms or conditions prompting the cath lab visit for which the patient presented is due to an abrupt transient complete loss of consciousness associated with inability to maintain postural tone with rapid and spontaneous recovery. It's also called fainting or passing out. Post-cardiac transplant would be selected if the patient's symptoms or conditions prompting the cath lab visit for which the patient presented is due to them receiving a cardiac transplant. Pre-operative evaluation would be selected if the patient's symptoms or conditions prompting the cath lab visit for which the patient presented requires a cardiac evaluation of the coronary arteries and or LV function. It is specific to capturing those patients who present for cardiac clearance for a surgical intervention. Evaluation for exercise clearance would be selected if the patient's symptoms or conditions prompting the cath lab visit for which the patient presented requires clearance to participate in an exercise program or cardiac rehab. The breadth of cath lab indications will provide the registry the ability to capture the broad spectrum of reasons why patients present for a diagnostic or PCI procedure. If none of the available cath lab indications apply to the patient then other is selected. In those instances please email the registry letting us know the patient condition that could not be adequately accounted for. The frequency of missing cath lab indications will be monitored for future consideration. While it is possible to select all that apply of these cath lab indications some definitions should not be selected together because they are mutually exclusive meaning both definitions cannot be true for the patient. There are two instances where cath lab indications are conflicting and should not be selected together. The first involves the indications of new onset angina and worsening angina. New onset angina is only applicable to patients who have no history ever of angina. Their diagnosis of angina is new while worsening angina is selected when the patient has a history of angina and it has gotten worse in either severity or frequency within the last two months. Lastly the indications of stable node CAD and suspected CAD should not be selected together. Stable node CAD identifies the patient has a history of coronary artery disease with with disease of 50 percent or worse in a single vessel and suspected CAD is selected when the patient has no such prior documentation. Sequence 7405 chest pain symptom assessment is indicating the chest pain symptom assessment as diagnosed by the physician or described by the patient that is bringing the patient to the cath lab to meet the target value of on current procedure. It can be coded based on provider documentation such as the patient presents with typical typical angina would support coding of typical or in the absence of provider documentation this data element is coded meeting the data definition criteria of each selection. Documentation of typical angina substernal chest discomfort with characteristic quality duration that is provoked by exertion or emotional stress and relieved by rest or nitrogen or CCS4 or unstable angina supports coding typical angina in sequence 7405 chest pain symptom assessment. Documentation of atypical angina or two of the three characteristics of typical angina or CCS1, 2, or 3 supports coding atypical angina in sequence 7405 chest pain symptom assessment. Documentation of non-anginal chest pain or one of the typical characteristics of angina or non-ischemic chest pain or costochondritis or chest wall pain supports coding non-anginal chest pain in sequence 7405 chest pain symptom assessment. Documentation of no symptoms no angina or asymptomatic or no complaints of pain supports coding asymptomatic in sequence 7405 chest pain symptom assessment. To code an angina equivalent the documentation must indicate that the symptom such as shortness of breath represents an angina equivalent and specify the chest pain symptom type typical or atypical. They are representative of to support coding 7405 chest pain symptom assessment.

sequence numbers

PCI

CVASC registry

procedure start and end times

angioplasty procedures

catheter placements

arterial access sites