Welcome and thank you for joining this learning activity titled CV ASC Registry Education to Sequence Numbers. This is a learning activity with focused education on the sequence numbers in the diagnostic only portion of the CV ASC registry. After participation in this learning activity, the learner should be able to identify, discuss, and explore the sequence number elements in the diagnostic only 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 CV ASC 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 home page. Now buckle in for some education time as we navigate the sequences in the registry. Sequence 7450 valvular disease stenosis type will populate when indications for cath lab visit is coded as valvular disease. This data element is indicating the cardiac valve or valves with stenosis as diagnosed by the physician six months prior to the current procedure. If no valve is stenosed, the data element would be left blank. Sequence 7451 valvular disease stenosis severity will populate when sequence 7450 valvular disease stenosis type is coded with any value. This data element is indicating the cardiac valve stenosis severity six months prior to the current procedure. When a range is provided, please code the highest value. The registry agrees the following words trace and trivial are reflected of mild and will support coding sequence 7451 as such. Sequence 7455 valvular disease regurgitation will populate when indications for cath lab visit is coded as valvular disease. This data element is indicating the cardiac valve or valves regurgitation as diagnosed by the physician six months prior to the procedure. If no valve has regurgitation, the data element would be left blank. Sequence 7456 valvular disease regurgitation severity will populate when sequence 7455 valvular disease regurgitation type is coded with any value. This data element is indicating the cardiac valve regurgitation severity six months prior to the current procedure. When a range is provided, please code the highest value. The registry agrees the following words of trace and trivial are reflective of mild regurgitation and will support coding sequence 7456. When preoperative evaluation is selected as a cath lab indication, sequence 7465 evaluation for surgery type will populate which is indicating the type of surgery for which the diagnostic coronary angiography is being performed. Whether it be a cardiac surgery which involves the coronary arteries valves or a structural repair of the heart or non-cardiac surgery involving the aortic arc or other body system. Functional capacity measured in METS measures the ability or limitation of a patient to perform various activities. Sequence 7466 functional capacity is indicating the most recent functional capacity of the patient as documented by the physician in the medical record six months prior to the start of the current procedure. Start of the current procedure is defined as what is coded in sequence 7000 procedure start date and time. The notes further clarify that there should be explicit documentation as part of the pre-op evaluation indicating the functional capacity to determine whether the patient should proceed to plan surgery. The metabolic equivalent of task or MET is a metabolic unit used to quantify the estimated energy requirements of various activities. However if the functional capacity of the patient is unknown then please select sequence 7467 functional capacity unknown. Surgical risk is assessed based on the patient's history of cardiac and comorbid disease functional capacity as well as the urgency and magnitude of the surgical procedure. Evaluation of surgical risk is determined by the physician and outlined according to the ACC AHA guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery. Sequence 7468 surgical risk is indicating the surgical risk category as documented by the physician in the medical record six months prior to the start of the current procedure. Again start of the current procedure is defined as the date and time coded in sequence 7000 procedure starting time. The notes further clarify that there should be explicit documentation by the physician indicating surgical risk to support the risk profile documented. When surgical risk is not documented then you will select low risk. Sequence 7469 solid organ transplant surgery is indicating if the pending surgery involves a solid organ transplant. Sequence 7470 solid organ transplant donor is indicating if the patient is the organ donor. Sequence 7471 solid organ transplant type is indicating the indicating the type of organ transplant surgery performed and is a select all field. Coronary circulation dominance is looking to capture the greater contributor to the perfusion distribution of the inferior surface of the left ventricle. Patients that arrive for a coronary catheterization will more often than not have different coronary anatomy. This data element can reflect that concept by looking at the posterior descending artery origin and distribution. If the posterior descending artery and posterolateral artery arise from the left circumflex you would capture this as left and vice versa. Codominant captures a distribution where the posterior descending artery arises from the right and the posterolateral artery arises from the left creating an equal distribution of the inferior surface of the left ventricle. Sequence 7500 coronary circulation dominance can be coded based on descriptive documentation that meets the definitions found in the data dictionary or on physician documentation alone such as the patient is left dominant, be coded as left. Because dominance does not change the registry will accept the value that is acceptable to code sequence 7500 from information found in a medical record that is greater than 30 days prior to the procedure. The only exception to this rule is that if the patient has a history of a heart transplant we want sites to ensure that they're reflecting dominance as reflected in the new heart. Sequence 7505 and sequence 7525 is looking at native or graft vessel stenosis and this captures that there is if there is native or graft vessel stenosis of 50% or greater focusing on the latest value within the last six months prior to the current procedure. The notes further clarify to identify the disease found in two millimeter or larger vessels or identify disease found in vessels less than two millimeters if they're planning on performing PCI or the patient's anatomy is two millimeters or less. It is acceptable to use prior cath lab visit information as long as there have been no changes in coronary anatomy. This includes stenosis determined via cardiac cath at another facility. This does not include collaterals. Stenosis represents the percentage diameter reduction ranging from 0 to 100 associated with the identified vessels. Percent stenosis at its maximal point is estimated to be the amount of reduction in the diameter of the normal reference vessel proximal to the lesion. In instances where multiple lesions are present enter the single highest percent stenosis noted. Sequence 7505 and 7227 is looking for the native or graft lesion segment number and this is using the coronary artery segment diagram available on the resources page. If the lesion is in a graft that indicate the segment location of the first anastomosis distal to the lesion and if it's above a Y graph you're going to indicate the segment of the most important distal vessel. Sequence 7508 and 7528 is looking for native graft coronary vessels stenosis and this is capturing the best estimate of the most severe percent stenosis in the segment of the native or graft vessel identified. Again it is acceptable to use prior cath lab visit information as long as there have been no changes in coronary anatomy. So this includes stenosis determined via a cath at another facility however this does not include collaterals. Sequence 7511 and 7531 native or graft vessel adjunctive measurements obtained is indicating if an invasive diagnostic measurement was obtained of the native or graft vessel intra procedure and prior to the intervention. Sequence 7512 7532 native or graft vessel fractional flow reserve ratio is indicating the lowest fractional flow reserve of the native or graft vessel intra procedure and prior to the intervention. Sequence 7513 7533 native or graft vessel instantaneous wave free ratio is indicating the lowest instantaneous wave free ratio also called IFR of the native or graft vessel intra procedure and prior to the intervention. The notes further clarify to accommodate for other assessment methods not collective specifically within the static data set. A CTFFR result or a resting non-hyperemic flow reserve ratio may also be coded in this field. The instructions to code is to code zero in this field to indicate ischemia was identified or an abnormal result. As well ischemia is defined as any one single of the following criteria a CTFFR of 0.80 or less, the Abbott RFR of 0.89 or less, the PDPA of 0.91 or less, the Boston Scientific DFR of 0.89 or less, the Boston Science DPR 0.89 or less, the Boston Scientific PDPA of 0.89 or less, the CathWorks FFR Angio 0.80 or less, the Medus Imaging QFR 0.89 or less, or physician documentation that the study results demonstrate ischemia. You will code one to it to indicate ischemia was not identified otherwise. Continue to enter the actual IFR value documented if IFR was used. Sequence 7514 and 7534 native or graft vessel intravascular ultrasonography is indicating the lowest minimal luminal area or MLA measured via IVAS of the native or graft vessel intra procedure and prior to the intervention. Sequence 7515 and 7535 native or graft vessel optical coherence tomography is indicating the lowest minimal luminal area measured via OCT of the native or graft vessel intra procedure but prior to the intervention. If disease has been identified in a graft vessel, sequence 7529 is indicating whether that was the lima, rima, SVG, or radial artery being used for the graft. If the vessel that was used for the graft was unknown, then you would select sequence 7530, cabbage graft vessel unknown. Each CVASC procedure pathway is assigned unique and specific events. The entire team, including ambulatory surgery center and office-based lab stakeholders, thoughtfully and concisely appointed these events to this 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 event that could be used within the registry, constraints are applied in the back end to allow certain events to appear in the specific pathway when using the data collection tool. Thus, the easiest means to know which events are captured for a single procedure is the data collection form. Sequence 9001 intra or post procedure events is indicating if the event occurred between the start of the procedure and the next procedure or discharge. 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 any occurrence between start of procedure and discharge. To code yes for bleeding at access site. There must be documentation the patient experienced external bleeding at the access or percutaneous site that's coded in sequence 7320 arterial access site that was observed and documented in the medical record. Then once that is identified, there must be any one of the following, a hemoglobin drop of three or more, a transfusion or a procedural intervention or surgery at the bleeding site to reverse stop or correct the bleeding. While there may be documentation that criteria number one or two or three took place, when there is no documentation reflecting the patient experienced external bleeding at the access site, this bleeding event would not be captured. To code yes for bleeding hematoma at access site, there must be documentation the patient experienced a hematoma at the percutaneous entry site as coded in sequence 7320 arterial access site that was observed and documented in the medical record. Then once identified, there must be any one of the following, a hemoglobin drop of three or more, a transfusion or a procedural intervention or surgery at the bleeding site to reverse stop or correct the bleeding. While there may be documentation that criteria one or two or three took place, when there is no documentation reflecting the patient experienced a hematoma at the percutaneous entry site, this bleeding event would not be captured. To code yes for bleeding other, there must be documentation the patient experienced a bleeding event not available for selection within the registry that was observed and documented in the medical record. Then once identified, there must be any one of the following, a hemoglobin drop of three or more, a transfusion or a procedural intervention or surgery at the bleeding site to reverse or stop or correct the bleeding. While there may be documentation that criteria one or two or three took place, when there is no documentation reflecting the patient experienced a bleeding event not available for selection within the registry, this bleeding event would not be captured. To code yes for bleeding retroperitoneal, there must be documentation the patient experienced retroperitoneal bleeding that was observed and documented in the medical record. Then once identified, there must be any one of the following, a hemoglobin drop of three or more, a transfusion or a procedural intervention or surgery at the bleeding site to reverse stop or correct the bleeding. While there may be documentation that criteria one or two or three took place, when there is no documentation reflecting the patient experienced retroperitoneal bleeding, this bleeding event would not be captured. Cardiac arrest is defined as an acute cardiac event documented by one of the following, ventricular fibrillation or rapid ventricular tachycardia or bradycardia with hemodynamic compromise, causing loss of consciousness or PEA or asystole. Once an acute cardiac event defined as above is met, then it needs to require cardiopulmonary resuscitation of two or more chest compressions or open chest massage, emergent temporary pacing, pericardiocentesis, institution of ECMO or defibrillation. As without these measures, death would have almost certainly resulted. Also note, if an event occurs that meets the above definition of cardiac arrest, you're gonna code yes, regardless of a resuscitation status, such as DNR, hospice or comfort care. Heart failure is captured when a patient is diagnosed with new onset or acute reoccurrence of heart failure that necessitated new or increased pharmacologic therapy. As there is no single diagnostic test for heart failure, it is largely a clinical diagnosis based on careful history and physical examination by an advanced practice professional. Myocardial infarction is captured when the patient experiences a new occurrence of biomarker positive myocardial infarction. At least one determination of biomarkers obtained no sooner than six hours after the procedure and preferably within the interval of six to 24 hours post procedure should be used. The notes further clarify for sites to code yes when there's new QAs diagnosed by advanced practice professionals are present with absent, incomplete or inconclusive biomarkers. Additionally, when biomarkers are not obtained in the setting of post PCI acute MI, yes will be coded. Stroke is captured when the patient experiences an ischemic or hemorrhagic stroke. Ischemic stroke is defined as an acute episode of focal or global neurological dysfunction caused by brain, spinal cord or retinal vascular injury because of infarction of the central nervous system tissue. A hemorrhagic stroke is defined as an acute episode of focal or global cerebral or spinal dysfunction caused by intraparenchymal, intraventricular or subarachnoid hemorrhage. If a patient experiences a subdural hematoma, these are considered intracranial hemorrhagic events but they're not strokes in and of themselves. Sequence 9002, intra post procedure events occurred is indicating if the specified event did or did not occur between the start of the procedure and until next procedure or discharge. The term procedure and the target value is in reference to the CAP PCI or EPDI 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 was initially built to handle one pathway per episode of care. Thus, the target value for an ASC is better understood if written any occurrence between start of procedure and discharge. Sequence 10101, discharge date and time is indicating the date and time the patient was discharged from your facility as identified in the medical record. Sequence 10105, discharge status is indicating whether the patient was alive or deceased at discharge. Sequence 10110, discharge location is indicating the location to which the patient was discharged. Home would be selected any time a patient returns to their place of residence. This includes assisted living facilities. Skilled nursing facility would be selected when the patient returns to a facility for a longer anticipated length of stay. An extended care or transitional care or rehab unit typically provides a high level of intensive therapy as well as specialized nursing and physician care. This discharge setting may also be called subacute care or long-term acute care. And when a patient is discharged to one of these types of facilities, this selection would be selected. Other would be selected when the patient discharges anywhere other than the options provided. This would include facilities such as a jail. If the patient is discharged or transferred to another hospital that provides acute care services, then acute care hospital would be selected. If the patient was discharged or eloped against medical advice, then left against medical advice would be selected. Sequence 15608, emergent transfer to acute care hospital is indicating if the transfer to the acute care hospital was done emergently. The term emergent is defined as a situation where the absence of immediate higher level of medical attention could result in a severe life-threatening or possibly disabling condition. If the patient was discharged to an acute care hospital, the suspected condition or conditions prompting the transfer are captured in sequence 15702, suspected conditions. The options include concerns for a gastrointestinal bleed, a retroperitoneal bleed, or another bleed that is neither gastrointestinal or retroperitoneal, NSTEMI, other vascular complications, stroke, or a TIA. If the suspected condition prompting the transfer is not available for selection, then other would be coded. In clinical scenarios where there is no suspected condition documented prompting the transfer, none documented would be coded. Each CV ASC procedure pathway is assigned unique and specific discharge medications. The entire team, including ambulatory surgery center and office-based lab stakeholders, thoughtfully and concisely appointed these medications to their 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 discharge medication that could be used within the entire registry, constraints are applied in the backend to allow certain medications to appear once a specific pathway is selected in the data collection tool. Thus, the easiest means to know which medications are captured for a single procedure is the data collection form. Additionally, discharge medications will only be made available for capture if the patient is alive at discharge, or rather, and they discharge anywhere other than another acute care hospital or leaving against medical advice. Discharge medications are controlled by the medication master file, which is managed by the NCDR. If additional medications 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 10205, discharge medications prescribed, is capturing if a certain medication was prescribed, not prescribed, or was not prescribed for either a medical or patient reason on discharge. Yes would be selected if a certain medication was prescribed on discharge. No, no reason would be selected if a certain medication was not prescribed post-procedure or for discharge, and there was no mention of a reason why it was not ordered within the medical documentation. No medical reason would be selected if a certain medication was not prescribed post-procedure or for discharge, and there was a reason documented related to a medical issue or concern for not prescribing that medication. Documentation that is acceptable to code no medical reason must include a specific reason that the medication was not prescribed. Examples of acceptable documentation include physician documentation that the medication was not prescribed due to an existing medical condition, an intolerance or allergy to a medication, active bleeding, oral anticoagulation therapy as pre-arrival medication, as a medical exception to prescribing aspirin. Examples of acceptable documentation continued include specific reasons for not prescribing one medication would apply to the entire class. This gives the physician credit for addressing and assumes reasons provided applies to the entire class. As an example, documentation of no plavix due to bleeding risk supports coding no medical reason for all P2Y12 inhibitors. Another example of acceptable documentation continued includes general clinician documentation, medication contraindication, without specifying the exact contraindication. As an example, documentation of patient has contraindication to aspirin supports coding no medical reason for aspirin. Documentation that is either absent or too generic or general is not acceptable to support coding. The physician's documentation may indicate a decision was made not to prescribe a specific medication. However, the reason or a contraindication is not implicitly provided. No patient reason would be selected if a certain medication was not prescribed post-procedure or for discharge, and there was a reason documented related to the patient's preference. If you are abstracting in the diagnostic coronary angiography only, or PCI with or without coronary angiography pathway, and have indicated a statin was prescribed on discharge, the category of the medication dose prescribed on discharge is captured in sequence 10207, discharge medication dose. The options include low, moderate, or high. The dose definitions came directly from the ACC AHA guidelines on the management of blood cholesterol and will be coded based on them. Meaning, if a torvastatin 40 milligrams was prescribed on discharge, high would be coded. The notes in the coding instructions further educate sites that if a statin dose prescribed is outside intensity category, this data element would be left blank. As an example, if simvastatin five milligrams was prescribed on discharge, this data element would be left blank. Additionally, if the statin dose prescribed overlaps two categories, sites will code the lower intensity category. If the medication dose category was coded as either low or moderate, sites will have the opportunity to indicate if there was either a patient or medical reason that a high dose statin was not prescribed on discharge.

CV ASC Registry

sequence numbers

valvular disease

surgical risk assessment

coronary circulation dominance

discharge procedures

coding proficiency