Welcome to Lesson 2 of Metric No. 40, Risk-Standardized Bleeding, in which we will continue our education by reviewing metric criteria through case scenarios. For our first case scenario, our documentation is as follows. The patient arrives with a diagnosis of STEMI and receives immediate PCI. Their pre-procedure hemoglobin is 15.8. Their post-procedure hemoglobin is 11.6. There's no documentation of a bleed. How is sequence number 9002, intra-post-procedure events coded? Number one, no. Or number two, yes. Please take a moment to review the documentation and the question before making your final determination. The answer is number one, no. Bleeding at a specific site, whether it's access site, GI, GU, hematoma, retroperitoneal, or other, will only be captured in sequence number 9002 when the bleed is literally observed and documented in the medical record, and one of the three conditions in the coding instructions are met. Our follow-up question, is the procedure identified as an observed bleeding event in Metric 40, Risk-Standardized Bleeding? Number one, no. Or number two, yes. And the answer is number two, yes. The patient experienced a 4.2 gram per deciliter drop from 15.8 to 11.6, meeting the criteria of outcome number five. Their pre-procedure hemoglobin was less than 16, and the hemoglobin drop was greater than or equal to four, and a mechanical ventricular device was not used. The documentation for our second case scenario. The patient arrives with STEMI and receives immediate PCI. Their pre-procedure hemoglobin is 15.8, and post-procedure hemoglobin is 11.6. There's no documentation of a bleed, and intra-aortic balloon pump is inserted during the procedure. So how is sequence number 9002 intra-post-procedure events coded? Number one, no. Or number two, yes. Please take a few moments to review the documentation and the question before making your final determination. The answer is no. Again, bleeding at a specific site, whether it be an access site, GI, GU, hematoma, retroperitoneal, or other, will only be captured in sequence 9002 when the bleed was literally observed and documented in the medical record, and when one of the three conditions in the coding instructions are met. Our follow-up question, this procedure identified as an observed bleeding event in metric 40 risk-standardized bleeding. Number one, no. Or number two, yes. The answer is number one, no. The patient experienced the 4.2 gram per deciliter drop in hemoglobin. A mechanical support device was used and coded, making it so that outcome number five criteria was not met. We discussed that none of the other criteria for outcomes number one through four were met either. For our third case scenario, we have some of the same features, but some new information. The patient arrives with STEMI and receives immediate PCI. Pre-procedure hemoglobin is 15.8, and post-procedure hemoglobin is 11.6. An intra-aortic balloon pump is inserted during the procedure. The second day post-PCI, there's a documented hematoma at the access site. The question is, was sequence number 9002 intra- and post-procedure events coded? Number one, no. Or number two, yes. Take a few moments to review the documentation and the question before making your final determination. The answer is number two, yes. A documented observed hematoma at the primary access site in conjunction with the greater than or equal to three gram hemoglobin drop supports coding yes to sequence number 9002 for bleeding hematoma at access site. We again ask the question, procedure identified as an observed bleeding event in metric 40? Number one, no. Or number two, yes. The answer is number two, yes. Patient experienced an observed documented bleeding event captured in sequence 9002. It occurred post-PCI day two, which is within 72 hours, as determined in sequence 9003. We said no because a mechanical ventricular support device was used. Note that the use of the mechanical ventricular support device would make it so that outcome five is not met. That does not exclude the patient from the model when another outcome, in this case, the first outcome, is met. Case scenario number four. Our patient arrives with STEMI and receives immediate PCI. Their procedure hemoglobin is 15.8 and post-procedure hemoglobin is 11.6. Intra-aortic balloon pump is inserted during the procedure. Day four, post-PCI, there is documented bleed at the intra-aortic balloon pump site. How is sequence number 9002 intra-post-procedure events coded in this scenario? One, no. Or number two, yes. Take a few moments to review the documentation and the question before making your final determination. The answer is number two, yes. The rationale being that we have a documented observed hematoma at the intra-aortic balloon pump site. Function with the greater than or equal to three drop in hemoglobin. Supports coding yes to sequence 9002 intra-post-procedure events for bleeding other. Remember the target value in sequence 9002. Occurrence between start of procedure and until next procedure or discharge. Once again, follow up with the question, is the procedure identified as an observed bleeding event in metric 40? One, no. Or number two, yes. The answer is number one, no. We coded the bleeding site and source in sequence number 9001, 9002, and 9003 following the coding instructions as usual. The model determined that it did not qualify as a bleed because it did not take place between the start of the procedure and 72 hours after PCI. Finally, none of the other outcome criteria was met. And therefore, this procedure is not recognized as a metric 40 observed bleeding event by the risk model. Fifth and final iteration of this case scenario. The documentation has the patient arriving with STEMI and receiving immediate PCI. Their post-procedure hemoglobin is 15.8. Their post-procedure hemoglobin is 11.6. The aortic balloon pump is inserted during the procedure. Or post-PCI, there's a documentation of a bleed at the intra-aortic balloon pump site. Five, hemoglobin is 8.4, and they are transfused one unit of packed red blood cells. The initial question, once again, is how is sequence number 9002 intra-post-procedure events coded? No. Number two, yes. A few moments to review the documentation and the question before making your final determination. The answer is number two, yes. An observed hematoma at the intra-aortic balloon pump site in conjunction with the greater than or equal to 3 gram drop in hemoglobin supports coding yes to sequence number 9002 for bleeding other. Remember the target value here in sequence number 9002, any occurrence between start of procedure and until next procedure or discharge. And now our final follow-up question. Is the procedure identified as an observed bleeding event in metric 40, risk-standardized bleeding? Number one, no. Or number two, yes. And the answer is number one, no. To review, a documented bleed was coded in sequence number 9001 through 9003. However, it did not occur during the PCI or meet the 72-hour window. The patient did not have a hemorrhagic stroke or tamponade anytime intra-post-procedure to meet the target value. The patient had a red blood cell transfusion. However, the target value for sequence 9277 transfusion PCI is any occurrence between start of procedure and 72 hours after current procedure. And therefore, no is coded. Additionally, the patient did not have surgery and therefore the coding instructions for sequence 9278 are not met either. Lastly, the patient lost 4.2 grams per deciliter of hemoglobin pre-PCI to post-PCI. However, mechanical ventricular device kept them from meeting outcome number five. This concludes lesson two of metric 40 risk-standardized bleeding in which we gained a further understanding of metric criteria through case scenarios. Thank you for your participation. For more information, visit www.FEMA.gov

Lesson 2

Metric No. 40

Risk-Standardized Bleeding

case scenarios

metric criteria