STSTVT-1026 - Seq# 10116 Cardiac Rehabilitation Referral-STSTVT-1026

Video Transcription

Video Summary

A 66-year-old woman underwent successful mitral clip placement and discussed cardiac rehabilitation with the inpatient nurse, but no formal referral was made at discharge. She was sent to a short-term rehab facility. For Sequence 10116, the correct coding is <strong>No — Reason not documented</strong>. Although CR was discussed, there was no documented patient refusal, medical reason, or healthcare system reason that explained why a referral was not provided. To code <strong>Yes</strong>, the referral must be transmitted and documented prior to discharge, or refusal must be documented.

Keywords

mitral clip placement

cardiac rehabilitation

discharge referral

no referral documented

inpatient nurse