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 8021, Severe Calcification, is indicating if there was severe calcification of the lesion. Per the notes section, to support coding, there must be documentation of severe calcification specific to the lesion treated during the PCI procedure by the interventionalist in order to code yes. The registry has agreed the following words are synonymous with severe and will support coding yes, which include extreme, heavy, and critical. Sequence 8022, Bifurcation Lesion, is indicating if the treated lesion is at a significant bifurcation, trifurcation, or a more complex branch point. The notes further clarify that in a bifurcation or branch lesion, the plaque extends from at least one of the limbs to the branch point and need not progress down all the proximal and distal branches. To further clarify, this element seeks to capture a bifurcation when PCI is performed on two or more vessels with devices deployed in each. This can be determined based on the information provided and solely utilizing the coronary segment diagram. Sequence 8023, Guidewire Across Lesion, is indicating if a guidewire successfully crossed the lesion. If a device was deployed, meaning used as designed, so a balloon was inflated, a stent was placed, aspiration was attempted, with a thrombectomy device, etc., during the procedure, yes would be coded in sequence 8024 device deployed. If yes is selected for any lesion, at least one intracoronary device must be specified. Sequence 8025, Stenosis Post-Intervention, is capturing the post-intervention percent stenosis for the treated lesion that meets the target value of the highest value on current procedure. Sequence 8026, Timmy Flow Post-Intervention, is indicating the lowest post-intervention timmy flow through the lesion on current procedure. If a lesion spans multiple segments with different timmy flow, code the lowest timmy flow within the entire lesion. This can be coded based on physician documentation. Otherwise, the only descriptive terms allowed for coding of timmy are those in the data definitions for each data element. Sequence 8028, Intracoronary Devices Used, is indicating all devices utilized, inflated, deployed, placed, or otherwise used for the purpose of mechanical revascularization during the current procedure. If a single device was utilized on multiple lesions, specify it only once, such as the balloon was used to dilate two separate lesions, you're only going to list it once. Every treatment and support device utilized during the procedure should be specified. Each intracoronary device entered must be associated with at least one lesion. In the PCI section, you can also capture and track IVUS and OCT usage during a PCI procedure. This was an update. Why are we doing this? Because IVUS and OCT are utilized during PCI as best practice because it provides detailed cross-sectional images, lumen dimensions, lesion length, plaque morphology and location, evidence of thrombus, dissection, etc., and confirmation of stent apposition and expansion. As well, there is a heightened interest in tracking and benchmarking usage of these. Here we will talk about lesions and devices section, the coding guidance when an OCT or IVUS is used during a PCI procedure. You will follow the data dictionary coding instructions and target values for guidewire across lesion and devices deployed. If a guidewire has crossed the lesion and a mechanical revasc device was utilized, then any and all of IVUS and OCT within the lesion segments warrant identifying the applicable device in sequence 8027 and 8028 intracoronary devices used. What this can mean is that you may be coding IVUS usage in both the coronary anatomy section and the lesions and devices section if this criteria is met. As a coding example to demonstrate this coding advice, let's say we have a patient who had PCI to their proximal LAD. IVUS was utilized to confirm the optimal stent size. Then a Zions drug eluting stent was deployed. Zions was added to the device list and in this scenario, IVUS will also be added to the device list. Sequence 8030 intracoronary device associated lesion is identifying the lesion or lesions in which this device was used. Sequence 8031 intracoronary device diameter is indicating the diameter of the device in millimeters and sequence 8032 device length is indicating the length of the device in millimeters. Sequence 9145 coronary artery perforation is specific to the PCI procedure type and would be captured if there was angiographic or clinical evidence of a coronary artery perforation observed on the current procedure. A coronary artery perforation occurs when there is angiographic or clinical evidence of a dissection or intimal tear that extends through the full thickness of the arterial wall. A dissection is defined as the appearance of contrast materials outside of the expected luminal dimensions of the target vessel and extending longitudinally beyond the length of the lesion. Because dissections are a frequent occurrence during PCI, the intent of this data element is to capture the occurrence of a significant dissection as defined by the data definition and one that is witnessed to occur during the current PCI procedure. Typically, dissections that are not flow-limiting are considered type A or B and are not captured. However, significant dissections are captured if they are type C dissections in the presence of ischemia or type D through F dissections, all of which are further described as type C which is persisting contrast medium extravasations, type D spiral-filling defect with delayed but complete distal flow, type E persistent filling defect with delayed antegrade flow, or type F filling defect with impaired flow and total occlusion. 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 the respective pathway based on reporting needs and keeping in mind the need for a lean dataset. So while the data dictionary lists every possible event that could be used within the registry, constraints are applied in the backend 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 have 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 gastrointestinal, there must be documentation the patient experienced gastrointestinal 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 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 gastrointestinal bleeding, this bleeding event would not be captured. To code yes for bleeding genitourinary, there must be documentation the patient experienced genitourinary 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 or stop or correct the bleeding. While there may be documentation that criteria 1 or 2 or 3 took place, when there is no documentation reflecting the patient experienced genitourinary bleeding, this bleeding event would not be captured. To code yes for bleeding hematoma at access site, there must be documentation that 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 1 or 2 or 3 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, stop, or correct the bleeding. While there may be documentation that criteria 1 or 2 or 3 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 1 or 2 or 3 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 going to code yes regardless of a resuscitation status such as DNR, hospice, or comfort care. Cardiac tamponade is captured when a patient experiences fluid in the pericardial space compromising cardiac filling and requiring intervention. Tamponade must be documented by either 1. echocardiogram showing pericardial fluid and signs of tamponade such as right heart compromise or 2. systemic hypertension, excuse me, systemic hypotension due to pericardial fluid compromising cardiac function. To code cardiogenic shock, it must first be clear that cardiac dysfunction is present. Evidence of cardiogenic shock and at least one of the following are necessary to code yes for cardiogenic shock. Either the patient has sustained, defined as longer than 30 minutes, an episode of systolic blood pressure less than 90, or and a cardiac index of 2.2 or less, or the requirement or the requirement or perineural inotropic support or vasopressor agents or mechanical support to maintain blood pressure or the cardiac index above those levels. Of note, transient episodes of hypotension reversed with fluids or atropine do not constitute shock. The hemodynamic compromise must persist for at least 30 minutes. Additionally, the registry recognizes the inherent challenges in capturing all aspects of a patient's clinical condition with data elements addressing cardiogenic shock. We have accepted that all the nuances of a definition would not need to be met in their entirety to code. However, it is important that there should be some evidence that data definition being met or physician diagnosis or documentation to support coding so that presumptive coding does not occur and so that data is consistently captured throughout the registry. 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 twenty four hours post procedure should be used. The notes further clarify for sites to code yes when there's new QA's 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. 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 9275, packed red blood cell transfusion, is indicating if there was a transfusion of packed red blood cells any time between start of procedure, as coded in sequence 7000, procedure start date and time, 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 8505, post-procedure hemoglobin, is indicating the lowest hemoglobin value 72 hours after the current procedure. If a hemoglobin was not drawn 72 hours after the current procedure or by discharge, then sequence 8506, hemoglobin not drawn, would be selected. 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 longer, 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 the date and time the patient was discharged. It's 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.

CVASC Registry Education

sequence numbers

PCI registry

severe calcification

bifurcation lesion

guidewire success