Welcome to Lesson 3 of CATH PCI Registry Metric Number 45, Cardiac Rehabilitation Referral. In this lesson, we offer the opportunity to apply the information discussed in previous lessons by presenting six unique case scenarios. Case Scenario Number 1, the documentation goes as follows. On Friday, a 75-year-old male is admitted with chest pain on exertion. Serial troponins are drawn and come back positive, and the patient is diagnosed with a non-ST-elevated MI. On Saturday, the patient goes to the cath lab and has a stent placed to a 90% mid-LAD lesion. On Sunday, the physician orders cardiac rehab, and the patient is discharged. The patient receives discharge instructions, which include cardiac rehab information, including exercise, diet modification, medication management, and risk factor reduction. On Monday, the cardiac rehab staff sets up Phase II outpatient cardiac rehab for the patient, faxes the patient's referral information, and contacts the patient by phone to inform them. How is Sequence Number 10116, Cardiac Rehabilitation Referral, coded? Number 1, yes. Number 2, no, reason not documented. Number 3, no, medical reason documented. Or Number 4, no, healthcare system reason documented. Please take a moment to review the documentation and selections. And the answer is number two, no, reason not documented. Providing the patient an educational packet containing information about cardiac rehab at discharge, as well as discharge instructions that include information regarding exercise, diet modification, medication management, et cetera, does not qualify as a referral to a Phase II cardiac rehab program. We do appreciate the logistical challenges of providing the referral for same-day discharges, as well as after hours, on weekends, and holidays, and the efforts taken after discharge to provide the patient with the referral. However, the metric is designed to address the site-specific variation in how referrals are provided to patients, and providing the referral prior to discharge is associated with improved cardiac rehab compliance after PCI. If a cardiac rehab referral is not provided at discharge for a patient-centered reason that is neither a medical reason nor a healthcare system reason, please code no, reason not documented. Now we present case scenario number two, and the documentation is as follows. A 60-year-old female receives PCI to a lesion spanning the proximal and mid-LAD. Her cardiologist orders cardiac rehab. The staff attempts to inform the patient of the benefits of cardiac rehab and their cardiac rehab options. However, the patient refuses. Documentation in the medical record supports that a cardiac rehab referral order was initiated and the patient declined. We ask the question, how is sequence number 10116 cardiac rehab referral coded? Number one, yes. Number two, no, reason not documented. Number three, no, medical reason documented. Or number four, no, healthcare system reason documented. Please take a moment to review the documentation and selections. And the answer is number one, yes. If the cardiac rehab consult is made and there is an attempt to inform and discuss cardiac rehab with the patient and documentation of the patient's refusal, or any reason, yes is coded in sequence 10116 cardiac rehab referral. To clarify, if documentation in the medical record exists noting that the provider has informed and discussed referral to cardiac rehab or secondary prevention program with the patient, but that the patient refuses a referral, then the healthcare provider would not be expected to send communication about the patient to the cardiac rehab or secondary prevention program. This is consistent with HIPAA confidentiality regulations and shared decision-making, and performance would then be considered met by the provider, preventing unjust penalization of the provider. Now we present case scenario number three, and the documentation is as follows. An 88-year-old female with a history of diabetes, hypertension, and chronic renal insufficiency complains of progressive dyspnea accompanied by chest pressure. Her prior cardiac cath revealed a severely calcified 80% lesion to her mid-RCA, and she now presents for a planned PCI with a rotoblader. During the procedure, the operator is unable to deliver a balloon or stent, and the patient is discharged home the following day. The provider documents unsuccessful PCI, continued medical management, cardiac rehab not indicated. We ask the question, how is sequence 10116 cardiac rehab referral coded? Number one, yes. Number two, no, reason not documented. Number three, no, medical reason documented. Or number four, no, healthcare system reason documented. Please take a moment to review the documentation and selections. The answer is number two, no, reason not documented. The rationale behind coding this way is that all PCI procedures attempted are eligible for coding, regardless of whether they are deemed to be successful or not. As neither a medical or healthcare system reason was documented as a reason for not initiating the referral, no, reason not documented is the appropriate selection. Let's move on to case scenario number four. The documentation is as follows, a 38-year-old male presents to the emergency department with complaints of chest pain at rest. The patient has multiple cardiac risk factors and is determined to be noncompliant with his medication regimen. He is diagnosed with unstable angina, undergoes a cardiac catheterization, and is found to have severe 90% lesions in his distal RCA and ramus. He receives PCI to both vessels. After the procedure, the patient is transferred to the recovery area and awaits a bed on a telemetry unit with the plan to be discharged the following day. The patient refused to stay overnight and leaves against medical advice. The question is asked, how is sequence 10116 cardiac rehab referral coded? Number one, yes. Number two, no, reason not documented. Number three, no, medical reason documented. Or number four, no, healthcare system reason documented. Please take a moment to review the documentation and selections. The answer is number two, no, reason not documented. In this scenario, the patient's decision to leave against medical advice would not qualify as a medical or healthcare system reason for not receiving a referral, and the correct selection is no, reason not documented. Next up is case scenario number five. A 70-year-old male with recent history of STEMI recently had PCI performed to their proximal LAD. The patient now returns for a staged PCI of the mid-circumflex. The physician documents that the patient is currently enrolled in a phase II cardiac rehab program and that they are to continue participation in the program upon discharge. How is sequence number 10116 cardiac rehab referral coded? Is it number one, yes? Number two, no, reason not documented. Number three, no, medical reason documented. Or number four, no, healthcare system reason documented. Please take a moment to review the documentation and selections. And the answer is number one, yes. If the patient is currently enrolled in cardiac rehab, and if there is evidence in the medical record for the patient to continue with their current cardiac rehab at the time of discharge, then yes can be coded for sequence 10116 cardiac rehab referral. A new referral would not be required in this instance. Now we present our last case scenario, number six. The documentation is as follows. A 76-year-old female patient with a history of diabetes, hypertension, and a previous MI undergoes a diagnostic angiography, and 90% lesions in both her proximal LAD and mid-circumflex are discovered. The operator is unable to treat the LAD lesion due to difficult anatomy and an irregular takeoff from the distal left main. Surgeon is consulted for possible CABG, and arrangements are made for the patient to undergo surgery in one week. The physician documents that the patient is to avoid strenuous activity, and that cardiac rehab is not indicated until after the patient undergoes surgery due to the risk of ACS, secondary to severe CAD. One last time, we ask the question, how is sequence number 10116 cardiac rehab referral coded? Is it number one, yes? Number two, no, reason not documented? Number three, no, medical reason documented? Or number four, no, healthcare system reason documented? Please take a moment to review the documentation and selections. And the answer is number three, no, medical reason documented. When the cardiologist believes that it would be inappropriate or dangerous for the patient to initiate a phase two cardiac rehab program at discharge, and there is supporting documentation in the medical record addressing this concern, then no, medical reason documented can be coded in sequence 10116, cardiac rehab referral. This concludes lesson three of cath PCI registry metric number 45, cardiac rehab referral. In this lesson, we offered the opportunity to apply the information discussed in previous lessons by presenting six unique case scenarios. Thank you for your participation.

CATH PCI Registry Metric Number 45

Cardiac Rehabilitation Referral

case scenarios

patient compliance

medical necessity