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 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 with 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, 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 planned surgery. 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 start date and 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 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 posterior lateral 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 posterior lateral 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. As 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 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 2 millimeter or larger vessels or identify disease found in vessels less than 2 millimeters if they're planning on performing PCI or the patient's anatomy is 2 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. The 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, then 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 vessel 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. 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 and 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 and 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 collected specifically within the static dataset. 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 0 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 of 0.89 or less, or physician documentation that the study results demonstrate ischemia. You will code 1 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 IBIS 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. When coding sequence 7800 PCI status, the patient condition drives the selection of the status by meeting the definition. The status is determined at the time the operator decides to perform a PCI that meets the data definition. Selections include elective or urgent. To code elective, the PCI procedure could be performed on an outpatient basis or during a subsequent hospitalization without significant risk of infarction or death. For stable patients, the procedure is being performed during this hospitalization for convenience and ease of scheduling and not because the patient's clinical situation demands the procedure prior to discharge. If the diagnostic path was elective and there were no complications, the PCI would also be elective. To code urgent, the PCI procedure should be performed on an inpatient basis and prior to discharge because of significant concerns that there is risk of ischemia, infarction, or death. Patients who are outpatients or in the emergency department at the time that the cardiac catheterization is requested would warrant an admission based on their clinical presentation. Sequence 7815, Decision for PCI with Surgical Consult, is indicating if a cardiac surgical consult and recommendation were obtained prior to engaging in this PCI procedure. The notes further clarify to code no if a cardiovascular consult or recommendation was obtained after the start of the PCI, defined as guidewire insertion, as the intent is to capture if a surgical consult was obtained that informed the decision for this PCI procedure. Sequence 7816, Cardiovascular Treatment Decision, is indicating if the cardiovascular surgery recommendation and or patient family decision resulted in surgery not being recommended, surgery recommended but the patient or family declined, or surgery recommended and the patient family accepted. Sequence 7820, PCI for Multivessel Disease, is indicating if the PCI procedure was performed in the presence of multivessel disease. The notes further clarify what constitutes multivessel disease and to code yes if this is the initial or first PCI procedure for the cath lab indication and the patient has obstructive disease of 70% stenosis or worse in two or more coronary vessels and or disease of 50-70% stenosis in two or more coronary vessels with a non-invasive FFR or IFR evidence of ischemia in that territory and or there is left main stenosis of 50% or worse. A coronary vessel is defined as the LAD and any of its branches, the left circumflex and any of its branches, the RCA and any of its branches, and a true ramus branch of two millimeters or larger. As well, the site would code yes if this is a subsequent planned staged PCI procedure of a vessel not treated during their initial PCI procedure. That first PCI could have been during a prior admission or during this admission but it must have occurred within 90 days of the initial PCI procedure. For patients with multivessel disease, sequence 7821 multivessel procedure type will differentiate the type of multivessel PCI procedure that was performed during the lab visit. So if this PCI procedure is the initial, the first for the cath lab indication, the initial PCI would be coded. But if this PCI procedure is the subsequent, a planned staged PCI procedure for a vessel that was not treated during the initial PCI procedure, and again it could have occurred within the last 90 days, then staged would be coded. Sequence 7825 PCI indication is capturing the reason the PCI is being performed that meets the target value of the highest value at the start of the current procedure as coded in sequence 7000 procedure starting time. Therefore, anything that is learned or occurred during the procedure will not be captured. This is a single selection field and it correlates to what information was captured and indications for cath lab visit as they are integrated or related. PCI indication selections include new onset angina of two months or less, stable angina, CAD without ischemic symptoms, or other. If PCI is performed for the patient's new onset angina, typical or atypical, that developed within the previous two months, and this correlates to the selection coded in indications for cath lab visit, the new onset angina, two months or less, would be selected. If PCI is performed for angina that had no change in frequency or pattern for the six weeks prior to this cath lab presentation, where angina is controlled by rest or oral or transcutaneous medications, and this correlates to the selection that you coded in sequence 7400 indications for cath lab visit, then stable angina would be selected. If PCI is performed for known coronary artery disease and there are no symptoms of ischemia, which would include typical angina, ST segment elevation, and this correlates to the selection coded in indications for cath lab visit, then CAD without ischemic symptoms would be selected. And finally, if the PCI is performed for a reason not available for selection, then other would be selected. This table reviews the sequence 7400 indications for cath lab visit running horizontally and their correlations for sequence 7825 PCI indication running horizontally. Please take a moment to review and know you can come back to this slide for additional education. Sequence 7831 syntax score should be completed using the syntax score one scale. This data element will rely on licensed provider documentation of the syntax score, whether it's numeric or the level, low, medium, or high for coding purposes. When there is no documentation in the medical record of the syntax score, the user will select sequence 7832 syntax score unknown. Sequence 7995 procedure medications administered is indicating which medications were administered 24 hours prior to the current procedure and the end of the current procedure as coded in sequence 7005 procedure ending time. All medications captured regardless of root will be collected. The only exception is a heparin that is part of a heparin flush. This would not be captured. Heparin flushes are used for sheath and catheter exchanges, et cetera, and priming, so on and so forth. And these are usually only a one unit to one ml ratio. Sequence 8000 lesion counter is a counter used to distinguish between multiple lesions on which a PCI is attempted or performed. From the registry perspective, treated segments or areas that are sequential or in order to one another, such as with a proximal mid and distal RCA lesion, would be coded as one lesion with each segment identified in sequence 8001, which we will discuss in another slide. Sequence 8001 native lesion segment number is indicating the segments that the current lesion spans. A lesion can span one or more segments. From the perspective of the registry, treated segments or areas that are sequential to one another, as with the proximal mid and distal RCA lesion, are coded as one lesion in the lesion counter with each segment identified in sequence 8001. Sequence 8004 stenosis immediately prior to treatment is indicating the percent diameter stenosis immediately prior to the treatment of the lesion. Sequence 8005 chronic total occlusion is indicating if the segment with 100% pre-procedure stenosis was presumed to be 100% occluded for at least three months before this procedure and not related to a clinical event prompting or leading to this procedure. If the segment with 100% pre-procedure stenosis was presumed to be 100% occluded for at least three months before this procedure and not related to a clinical event prompting or leading to this procedure was unknown, then you would select sequence 8006 chronic total occlusion unknown. Sequence 8007 TIMIFLO pre-intervention indicates the lowest pre-intervention TIMIFLO through the lesion on the current procedure. If a lesion spans multiple segments with different TIMIFLO, code the lowest TIMIFLO within the entire lesion. It is coded based on physician documentation, otherwise the only descriptive terms allowed for coding of TIMIFLO are those in the data definition for each data element in the absence of physician documentation to assure consistency in the capturing of these data elements. However, when a lesion is 100% occluded, it is understood to obstruct all antigrade flow and TIMIFLO can be coded for sequence 8007. Do note the intent of TIMIFLO grading system is to categorize antigrade flow. Perfusion from collaterals should not be counted when evaluating TIMIFLO. Sequence 8008 previously treated lesion is indicating if the lesion has been treated before in the current or a prior episode of care. The notes further clarify to code no if the only prior treatment was CABG or if the only treatment of this lesion occurred during this PCI procedure. Sequence 8009 previously treated lesion date is indicating the date the lesion was previously treated. Sequence 8010 treated with stent is indicating if the previously treated lesion was treated with any type of stent in the current or prior episode of care. Sequence 8011 instant re-stenosis is indicating if the previously treated and stented lesion is being treated for instant re-stenosis, defined as a previously stented lesion that has 50% or greater stenosis. Sequence 8012 instant thrombosis is indicating if the previously treated and stented lesion is being treated because of the presence of thrombus in the stent. Sequence 8013 stent type is indicating the type of stent used in the previously treated lesion. If a patient has multiple stents in the lesion, code bioabsorbable over either of the other two options when it is present. If a drug eluting stent and bare metal stent are present in the lesion, code drug eluting stent. If the type of stent used in the previously treated lesion is unknown, please select sequence 8014 stent type unknown. Sequence 8015 lesion and graft is indicating if the lesion is in a coronary artery bypass graft. Sequence 8016 type of CABG graft is indicating if the type of bypass graft the lesion is located is a lemma, vein, or other artery. Sequence 8017 location and graft is indicating the location of the most severe stenosis if the lesion is in the graft. If the most severe stenosis is at the aortic anastomosis of the graft, three millimeters or less from insertion point, aortic would be the appropriate selection. If the most severe stenosis is in the body of the graft, body would be the appropriate selection. If the most severe stenosis is at the distal anastomosis of the graft, three millimeters or less from insertion point, distal would be the appropriate selection. Sequence 8018 navigate through graft to native lesion is indicating if treatment of the native artery lesion required navigating through a graft to reach the lesion. Sequence 8019 lesion complexity can be completed on physician documentation or on information reflected in the medical record that meets the definition. Additionally, if the lesion length is greater than two centimeters or 20 millimeters, then it is defined by registry standards as being a high C lesion and should be coded as such. Sequence 8020 lesion length is indicating the length of the treated lesion in millimeters. If the lesion length is not available, it is acceptable to code the length of the device used to treat the lesion. If multiple devices are used sequentially, total the individual device lengths. Information obtained after the baseline angiogram can be used to help determine lesion length. This slide is an example for total occlusions where the distal vessel cannot be visualized.

sequence numbers

valvular disease

surgical risk assessment

coronary circulation dominance

lesion details

stent type