CV ASC Registry Education-Seq#7015 (ICD Indication)

Video Transcription

Sequence 7015 ICD indication is captured on initial ICD-CRTD generator implants and generator changes.  Determination of primary versus secondary prevention is the responsibility of the implanting physician and must be documented in the current medical record.  Regarding secondary prevention, if the abstractor is unable to clarify with the clinician, but  they know the patient has survived one or more cardiac arrests or sustained ventricular tachycardia not due to a reversible cause, then the abstractor can code secondary prevention.  For instance, let's say the patient has had an episode of sustained ventricular tachycardia or V-fib arrest that has clear documentation that the event was not due to a reversible  cause. If this is not clearly documented in the medical record, we would ask that you clarify with  the implanting physician and have the documentation included in the medical record. Additionally, when talking about primary prevention, when there's documentation that the patient  meets the STD, HEFT, MAT-IT-1, or MAT-IT-2 criteria for ICD implant, this is sufficient  documentation for the capture of primary prevention because these were primary prevention trials.

Video Summary

ICD indication should be documented during initial implants and changes. Implanting physicians determine primary or secondary prevention, to be documented. For secondary prevention, if patient survived cardiac arrest or VT without reversible cause, code as secondary prevention if unable to clarify with clinician. Clear documentation on events like VT or V-fib without reversible cause is needed. Code for primary prevention if patient meets STD, HEFT, MAT-IT-1, or MAT-IT-2 criteria for ICD implant as these were primary prevention trials. Ensure all details are included in medical records for accurate coding.

Keywords

ICD indication

primary prevention

secondary prevention

documentation

coding