Welcome to Lesson 2 of CAHP PCI Registry, metric number 45, Cardiac Rehabilitation Referral, in which we will review the Cardiac Rehab Referral data element, including the data definition, target value, and coding selections. Cardiac Rehabilitation Referral is a physician performance measure and seeks to capture the physician's treatment of the patient. If there is no documentation of a referral for the patient to an outpatient cardiac rehabilitation program in the medical record, or documentation in the patient's medical record of a reason why such a referral was not made, then no will be coded for Sequence 10-116, Cardiac Rehabilitation Referral. To qualify, the program must be a Phase II outpatient cardiac rehab program. A home-based cardiac rehab course may qualify when the coding instructions are fully met. Sequence 10-116, Cardiac Rehabilitation Referral, is a required data element for both unsuccessfully attempted and successfully performed PCI procedures. Key components to meeting the definition of Sequence 10-116 to support coding yes are identified by asking the question, is the patient leaving the hospital with everything they need to attend cardiac rehab? This includes first, written documentation of the referral to a Phase II outpatient cardiac rehab program, and second, the provision of all necessary information allowing the patient to enroll. The second requirement can be accomplished in one of two ways. Communication to the CR program, including the patient's referral information, or the patient's information, including cardiovascular history, testing, treatments, etc., are provided to the patient to bring to their first cardiac rehab appointment. Examples might be a discharge summary or an office note handed to the patient for this purpose. The target value for Sequence 10-116, Cardiac Rehab Referral, is the value on discharge. Meeting the target value requires us to again beg the question, is the patient leaving the hospital with everything they need to attend cardiac rehab? To meet this target value, the cardiac rehab referral order must be placed and carried out prior to the patient's departure from the facility. Discharge planning can begin as soon as the patient arrives or is admitted to ensure that the steps are carried out accordingly and that all necessary provisions are provided to the patient prior to their departure. Coding selections for Sequence 10-116, Cardiac Rehab Referral, include no reason not documented, no healthcare system reason documented, no medical reason documented, and yes. No reason not documented is appropriate to code when a cardiac rehab referral has not been addressed or documented in the medical record. Not all provisions have been met and all provisions have been met, however, the target value on discharge has not been met. It is also appropriate to code no reason not document when a patient leaves the hospital against medical advice. The selection no healthcare system reason documented warrants coding when there is documented evidence that there is no cardiac rehab program available to the patient within 60 minutes of travel time from the patient's home, as well as documentation of a healthcare system reason that precludes referral to cardiac rehab, such as the patient being discharged to a nursing care or long-term care facility. No medical reason documented is the correct coding choice when there is documentation of a medical reason that precludes referral to cardiac rehab. An example might be documented evidence that the patient is deemed by the medical provider to have a medically unstable, life-threatening condition, or the patient has other cognitive or physical impairments that would contraindicate a cardiac rehab referral. To support coding yes in Sequence 10-116, we pose the question one last time, is the patient leaving the hospital with everything they need to attend cardiac rehab? If the answer to that question is yes, then it is appropriate to code as such in Sequence 10-116. To review, this includes a written documentation of the cardiac rehab referral to a Phase II outpatient cardiac rehab program, the provision of all necessary information, including the transfer of the patient's referral information either directly to the CR program or through the patient themselves by providing this information to them to present on their first visit. This concludes Lesson 2 of CAHPS PCI Registry Metric No. 45, Cardiac Rehabilitation Referral, in which we reviewed the cardiac rehab referral data element, including the data definition, target value, and coding selections. Thank you for your participation. 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Cardiac Rehabilitation Referral

Physician's Treatment

Outpatient Cardiac Rehab

Written Referral

Patient's Discharge