Patient evaluation risk stratification is completed when sequence 1, 2, 3, 6, 0, patient type is unsteady, unstable angina, or low risk chest pain. Sequence 1, 5, 4, 5, 3 risk stratification seeks to capture the patient's first risk stratification documented. Clinician documentation of low, intermediate, or high takes precedence over the numeric value documented between arrival at this facility and discharge. If the risk stratification is documented in a range, code the highest. Examples, a risk stratification documented as intermediate to high is coded as high, or a TIMI score of 2 to 3 is coded as intermediate. Code the first value if performed at this facility. If not performed at this facility, code the first value from the transferring facility. The risk stratification is coded first based on the clinician documentation of low, intermediate, or high. If the clinician did not categorize the risk, yet provided a numeric value, please code based on the numeric value documented in the medical record in accordance with the definitions provided. Low is indicated when the TIMI score is 0 to 2, the GRACE score is less than or equal to 108, the HEART score is less than 3, the modified HEART score is 0 to 3, or the EDACS score is less than 16. Intermediate is indicated when the TIMI score is 3 to 5, the GRACE score is 109 to 140, the HEART score is 4 to 6. If the modified HEART score or HERE score is greater than or equal to 4, or the EDACS score is greater than or equal to 16, code intermediate if clarification is not possible with the clinician. High is indicated when the TIMI score is greater than or equal to 6, the GRACE score is greater than 140, or the HEART score is 7 to 10. Please take this opportunity to strike out modified HEART, non-low risk greater than or equal to 4, and EDACS, non-low risk greater than or equal to 16 from the data dictionary. Sequence 15454, risk stratification not documented, seeks to capture when a risk stratification was not documented. Please note, if the risk stratification was conducted and acted upon, yet not documented in the medical record, code not documented. Sequence 15479, performed at transferring facility, seeks to capture when the first risk stratification was performed at the transferring facility between arrival at this facility and discharge. Only select risk score performed at transferring facility when a risk score was not performed at this facility and was performed at the transferring facility. Sequence 15480, risk stratification, risk assessment tool, seeks to capture the name or type of risk score documented for any occurrence between arrival at this facility and discharge. The selections for sequence 15480, risk stratification, risk assessment tool, will be discussed in the next few slides. The TIMI score is determined by the sum of the presence of seven variables at admission. One point is given for each of the following variables, greater than or equal to 65 years of age, greater than or equal to three risk factors for CAD, prior coronary stenosis greater than or equal to 50%, ST deviation on ECG, greater than or equal to two angina events in the prior 24 hours, use of aspirin in the prior seven days, and cardiac biomarkers that are elevated. The TIMI risk index is useful in predicting 30-day and one-year mortality in patients with NSTEMI ACS. The GRACE risk score predicts in-hospital and post-discharge mortality or myocardial infarction. It derives data from age, development or history of heart failure, peripheral vascular disease, systolic blood pressure, kill of class, initial serum creatinine concentration, elevated initial cardiac biomarkers, cardiac arrest on admission, and ST segment deviation. The sum of scores is applied to a reference nomogram to determine all-cause mortality from hospital discharge to six months. The HEART risk score is a clinical risk tool for rapid stratification of patients with chest pain. The score is composed of five components, history, ECG, age, risk factors, and troponin. Each of these components may be scored with 0, 1, or 2 points with a maximum risk score of 10 points. Patients are categorized as low risk, which is a heart, less than or equal to 3, intermediate risk with a heart score of 4 to 6, and high risk with a heart score greater than or equal to 7. The EDACS risk score predicts the short-term risk of major adverse cardiac events for adults presenting to the emergency department with possible cardiac chest pain. Patients are allocated according to age, sex, known CAD, CAD risk factors, and symptoms. No objective testing rules risk score, or the NOT rules risk score, identifies patients who are at low risk of ACS and could be discharged without further cardiac testing. The NOT rules uses cardiac risk factors, history of MI or CAD, age, serial troponin measurements, and a non-ischemic ECG. No STL depression or T-wave inversion in greater than one contiguous lead. Notice 15516, assessment tool not documented, seeks to capture if the risk stratification tool used was not documented in the medical record.

patient evaluation

risk stratification

medical records

clinician documentation

coding instructions