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The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Nov-09 Section NA SeqNo NA Field Name General Data Specification NA Jan-10 Jan-10 Feb-10 Oct-08 N/A N/A Case Inclusion N/A Question Can the STS sheets be a permanent part of the patient medical record? Since our organization is being benchmarked for 6 hours against others, I just wanted to have information why the STS changed it from 8 hour to 6 hours. I'm in the process of changing our protocol to this so we can have a better score and I have no concrete evidence that 6 hours are better then 8. Can you send me some information regarding which Cerebral oximeter to use? My anesthesia department is asking me for this information. Surely someone in STS could recommend a list of approved vendors? We had a pt who came in for Avr/Cabg and, prior to surgery, was found to have colon ca. It was decided to only do a CABG on him with the hope that, after recuperation, he could have colon surgery. However, upon induction, he had very high pa pressures and a iabp was inserted and the surgery was aborted. Within a few days, the iabp came out, he was extubated, and transferred to a larger facility. Do I code this? Patient died in OR prior to planned Hybrid procedure – crashed upon induction; no sternotomy; Vtach/fib arrest. Do I include this case in the database? No procedure performed. OR in and out times only. No incision times since EVH/sternotomy not performed. If so, is this an aborted procedure? How would I code this if I Response The STS cannot define what you include in your patient medical record. The information on the sheet must be supported in the medical record. In future reports it may be possible to footnote those fields that are benchmarks. It is a conflict of interest for STS to recommend vendors. This aborted case should not be included in the adult cardiac surgery database. Yes. This event needs to be captured and it would be coded as Other Cardiac Other. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 1 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Field Name Data Specification Question Response Should resection of subclavian aneurysm done as a primary procedure in which the aortic arch is not touched be included in the Adult Cardiac Database? The patient came in with an acute MI, had ECMO placed in the cath lab. The patient went to the OR but the surgeon deemed the patient unsalvageable and did not perform the procedure. The patient’s chest was opened but never put on bypass. Should this be included in the adult cardiac surgery database? We have many surgeries that follow in a same admission (e.g., ECMO, BIVAD, then heart transplant). Can we capture these surgeries like the Congenital Database captures all of their surgeries, by creating a new form and not by calling the second and third surgery a complication? Because theoretically, they are not complications, they are bridge to heart transplant. Can the upper/lower limits of the expected ranges be modified to allow for documentation of the absolute values? For example, the number of minutes it takes to harvest a saphenous vein may exceed the upper limit of acceptable data. Other examples include CPB time, cross clamp time, transfusions etc. There is a new study out regarding Staph aureus vaccine in adult patients having open heart surgery. Would this be coded as yes, patient in a known approved study or no because it does not contain actual This case should not be included in the adult cardiac surgery database as it is considered a peripheral vascular procedure. do? Dec-08 July-09 Oct-08 N/A N/A Operative N/A May-09 Nov-09 A 70 STS Trial Link Number Enter the number 1 (one) for a patient known to be in an IRB-approved clinical trial at the time of the surgical procedure. Enter the number 9(nine) for a patient known NOT to be in an IRB-approved clinical trial at the time Include in the database and code as Other Cardiac Other. No, do not create a new data collection form (DCF) for each procedure. The initial case should generate a DCF, then the additional procedures are captured in the Complications section. No, the valid data ranges in the data specifications cannot be modified until the next upgrade of the data specifications. Code NO the patient must be in an STS approved study. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 2 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jan-08 Sept2009 Section SeqNo Field Name B 171 Health Insurance Claim Number B 199 Hispanic or Latino Ethnicity Data Specification of the surgical procedure. Leave blank if it is not known whether or no the patient is enrolled in a clinical trial. Indicate the Health Insurance Claim (HIC) number of the primary beneficiary. This is an 11-digit number that uniquely identifies an individual for a claim. This field should be collected in compliance with state/local privacy laws. Question cardiac medications. Does it have to be 11 digits? Medicare is typically the 9 numbers (SS#) and 1 letter that = 10 not eleven. The HIC number consists of the SS# and an alpha-numeric identifier. This identifier is usually just one digit (but in few instances may be two digits). You may only have 10 digits to enter. It is the number found on patient's Medicare cards. If the patient is not a Medicare patient, they will not have a HIC number. This is a new field and may be changed in the next specs to be a "child" of the Payor-Government Health Insurance fields. Indicate if the patient is of Hispanic or Latino ethnicity as determined by the patient / family. Hispanic or Latino ethnicity includes patient report of Cuban, Mexican, Puerto Rican, south or Central American, or other Spanish culture or origin, regardless of race. This is a totally separate field from race. I find that if I mark no to all the other race fields and yes to ethnicity, the DQR comes back with race missing. Choose OTHER for race or leave blank. You know the patient is Hispanic or Latino ethnicity. Dose ethnicity need to be documented in the chart? Yes, the surgeon may include this in his H&P or it may be added as an anecdotal note. When the insurance sounds like a regular carrier but the patient is of Medicare age, should I still code commercial? Code the insurance carrier that is listed. What do I code if a patient has a Medicare HMO? All payor fields are "Select all that apply" as indicated on the Data Collection Form. Please code "Yes" to Seq# 248 re Medicare AND "Yes" to Seq# 255 re HMO. Oct-09 Oct-09 Jan-08 C 247 Payor Government Health Insurance C 248 Payor Government Health Insurance Medicare Indicate whether government insurance was used by the patient to pay for part or all of this admission. Government insurance refers to patients who are covered by government-reimbursed care. This includes Medicare, Military Health Care (e.g. TriCare), State-Specific Plan or Indian Health Service. Indicate whether the government insurance used by the patient to pay for part or all of this admission included Medicare. Response NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 3 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section SeqNo Field Name Data Specification Oct-08 Oct-08 Oct-09 Oct-08 Question Please clarify how to code patients with Medicare replacement plans. Do we code as Medicare and Commercial? I understand they are billed to the commercial provider, but are Medicare “replacement” plan with same benefits. How do you know if they are HMO or PPO replacement plans? Please clarify if a Medicare supplement should be coded as “Medicare” or “Commercial”. ACC codes a Medicare supplement as “Medicare”, so should STS patients be coded the same way? How do we identify FFS patients? C 310 Initial ICU hours Indicate the number of hours the patient received ICU level of care immediately following the initial surgery until the time of physical transfer out of ICU. Include ICU unit, post-anesthesia recovery, and similar critical care environments. For those sites who provide postop ICU level of care in one single unit (admission to ICU to hospital discharge), document the number of hours immediately following the initial surgery until a physician order is written to change the level of care provided. Our understanding is that the patient is still counted in ICU hours until the patient physically leaves the unit. The only time the level of care provided changes the ICU hours, is when the hospital provides all inpatient care in a single unit. Is this correct? Response They are coded as Medicare and Commercial. Code “Yes” to both Medicare and Commercial. If a patient has a Medicare supplement, both Medicare and the other carrier (most usually Commercial or HMO) would also be selected. These patients have Medicare part B. Discuss this with your billing department. Yes. Code ICU hours until the patient physically leaves the ICU. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 4 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section D SeqNo 390 Field Name RF- Family History CAD Data Specification Indicate if the patient has/had any direct blood relatives (parents, siblings, children) who have had any of the following DIAGNOSED at age less than 55 years for male relatives or less than 65 years for female relatives: 1. Coronary Artery Disease (angina, previous CABG or PCI) 2. MI 3. Sudden cardiac death without obvious cause. If the patient is adopted, or the family history is unavailable, code "No". Dec-09 Apr-08 D 392 RF - Last WBC Count Indicate the pre-operative White Blood Cell (WBC) count closest to the date and time prior to surgery. Oct-08 D 400 RF - Diabetes Indicate whether the patient has a history of diabetes, regardless of duration of disease or need for antidiabetic agents. Include on admission or preoperative diagnosis. Do not include gestational diabetes. Oct-08 Oct-08 Question Must the actual age of onset be documented to answer “Yes” to this question? Is it enough when the H&P states “father had an MI at an early age” or “mother had early onset of CAD”? Response Yes, the age needs to be documented. Version 2.61data specifications include age specifications for each gender. If a patient’s brother had a heart transplant but no reason as to why, is that considered family history? What are the units of measure for White Blood Counts? Our lab reports WBC/cu mm. For example, the normal range would be 4500-11000. The valid data range per the specs is 0.1 - 50.0. Would it be appropriate to code “Yes” for Diabetes if the patient was documented as being “pre-diabetic” with, or without an elevated HbgA1c? No, this is not family history. Can we code “Yes” for Diabetes based on an elevated HbgA1c (>5.8) on admission, in the presence of no prior documented diabetes? If the above two circumstances occur, does the fact that the patient receives diabetic teaching, and goes home on insulin or diabetic oral medication change the situation? (Essentially being a diagnosis of diabetes on admission.) No. The units of measure are in thousands. For example, 4500 would be entered 4.5. No. No. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 5 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date June-10 Section Jun-08 D 410 RF - Diabetes Control Jan-08 D 412 RF - Last A1c Level Oct-09 SeqNo Field Name Data Specification Indicate the method of diabetic control. Code the control method patient presented with on admission. Patients placed on a pre-operative diabetic pathway of Insulin drip but at admission were controlled with NONE, diet or oral method are not coded as insulin dependent. Choices are: None = No treatment for diabetes. Diet + Diet treatment only. Oral + Oral agent treatment (includes oral agent with/or without diet treatment). Insulin = Insulin treatment (includes any combination with insulin). Other = Other adjunctive therapy. Indicate the pre-operative HbA1c level closest to the date and time prior to surgery. Question If the patient presents on admission with steroid induced IDDM preoperatively and subsequently postoperatively with the steroid taper is not discharged on any diabetic medications. Can the risk factor diabetes be captured? If the patient is on both Oral agents and Byetta which do we choose? In the data specifications, HbA1c is a child field to Diabetes. Is it correct that you would not enter the A1c value unless you answer "Yes" to Diabetes? How old can an A1c level be to submit to the STS? Response Yes. Choose "Oral". That is correct. Diabetes must be coded "Yes" in order to complete the child field HbA1c. Capture the most recent. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 6 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Mar-08 Section D SeqNo 421 Field Name Dyslipidemia May-09 D 430 RF - Last Creat Lvl Data Specification Indicate if the patient has a prior history of dyslipidemia diagnosed and/or treated by a physician. As per National Cholesterol Education Program criteria can include documentation of: 1.Total cholesterol greater than 200mg/dl 2. LDL greater than or equal to 130mg/dl 3. HDL less than 40 mg/dl. Note: If treatment was initiated because the LDL was > 100 mg/dl (2.59mmole/l) in patients with known coronary artery disease, this would quantify as a "Yes". Any pharmacological treatment qualifies as a "Yes". Indicate the creatinine level closest to the date and time prior to surgery. A creatinine level should be collected on all patients, even if they have no prior history. A creatinine value is a high predictor of a patient's outcome and is used in the predicted risk models. Question The 2.61 specification does not include Triglycerides. If the total cholesterol, HDL and LDL do not meet the criteria for dyslipidemia but the triglycerides are 276 would we code "No" to dyslipidemia? Response Yes, code "No" to dyslipidemia. This change in the data specification is to provide consistency with the ACC. The preoperative risk factor of renal failure is determined by the most recent creatinine prior to surgery which does not always reflect the range of values the patients may have during the immediate preop period. The DM wondered if the most recent value was the most accurate value to use for determining postoperative renal failure or if there was a way to identify patients with poor renal function preop (eg: yes/no). Scenario: Preop creat 1.1, all prior values 1.5-2.0. Postop creat 2.3. Patient reported as having postop renal failure. Scenario: Elevated creat post cath trending down that gets diluted to a lower value the morning of surgery. The lower value does not reflect the renal injury that was associated with cath and the patient bumps up post-op so is coded as having renal failure postop. Using the most recent creatinine is the best indicator of post operative renal dysfunction. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 7 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Apr-08 Section D SeqNo 450 Sept2009 D Oct-09 Mar-08 Field Name RF - Renal FailDialysis Data Specification Indicate whether the patient is currently undergoing dialysis. 490 RF - Infect Endocard Indicate whether the patient has a history of infectious endocarditis documented by one of the following: 1. Positive blood cultures 2. Vegetation on echocardiography and/or other diagnostic modality 3. Documented history of infectious endocarditis. D 510 RF - Chronic Lung Dis D 520 RF Immunosuppressi ve Rx Indicate whether the patient has chronic lung disease, and the severity level according to the following classification: NO Mild: FEV1 60% to 75% of predicted, and/or on chronic inhaled or oral bronchodilator therapy. Moderate: FEV1 50% to 59% of predicted, and/or on chronic steroid therapy aimed at lung disease. Severe: FEV1 <50% predicted, and/or Room Air pO2<60 or Room Air pCO2>50. Indicate whether the patient has used any form of immunosuppressive therapy within 30 days preceding the operative procedure. This includes, but is not limited to inhaled or systemic steroid therapy and chemotherapy. This does not include topical applications, one time systemic therapy, or preoperative protocol. Question A patient is admitted with ARDS, MOSF and ARF and is found to have endocarditis. Dialysis is started on 2/19 and discontinued on 2/21. The patient has surgery on2/24. Should this be abstracted as dialysis pre-op? The patient presents with fungal endocarditis of the aortic valve, she had a recently been treated for mitral valve endocarditis. An abscess is found on the aortic valve. No vegetation is seen. Antifungals and antibiotics were started. The definition seems to imply that a bacterial source is needed. Do I code infectious endocarditis for this patient? I am concerned that people are coding chronic lung disease on the basis of PFT results. If an MD reads the result without seeing or knowing the patient how can he diagnose chronic lung disease. Explain how to code each level of chronic lung disease, Mild, Moderate or Severe. The data specification for RF Immunosuppressive RX states: This includes, but is not limited to, inhaled or systemic steroid therapy or chemotherapy. The Training Manual states: Do not include topical creams or inhalers that are steroidal in form. Please advise. Response No, not if the dialysis is discontinued. Yes, code endocarditis. While PFT results assess lung function this may not be the ideal tool for documenting CLD. Look for clarification in the next data specification upgrade. The training manual defines each level of CLD based on the medications, steroids or levels of O2 and CO2 on obtaining blood gases. Do not code RF-Immunosuppressive RX for inhalers that are steroidal in form. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 8 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Dec-09 Oct-08 July-09 Sept09 Section SeqNo D 530 D 540 Field Name RF - Peripheral Arterial Disease RFCerebrovascular Dis Data Specification Indicate whether the patient has a history of peripheral arterial disease (includes upper and lower extremity, renal, mesenteric, and abdominal aortic systems). This can include: 1. Claudication, either with exertion or at rest. 2. Amputation for arterial vascular insufficiency. 3. Vascular reconstruction, bypass surgery, or percutaneous intervention to the extremities (excluding dialysis fistulas and vein stripping). 4. Documented aortic aneurysm with or without repair. 5. Positive noninvasive test (e.g., ankle brachial index =<0.9, ultrasound, magnetic resonance or computed tomography imaging >50% diameter stenosis in any peripheral artery, i.e., renal subclavian, femoral, iliac). Peripheral arterial disease excludes disease in the carotid or cerebrovascular arteries. Indicate whether the patient has Cerebro-Vascular Disease, documented by any one of the following: CVA (symptoms >24 hrs after onset, presumed to be from vascular etiology); TIA (recovery within 24 hrs); Non-invasive carotid test with > 79 % diameter occlusion,; or Prior Carotid surgery. Does not include neurological disease processes such as metabolic and/or anoxic ischemic encephalopathy. Question Should the following medications be included as immunosuppressive therapy: Sulfasalazine Plaquenil Arava Would you code PAD if there is a traumatic occlusion that leads to an intervention (i.e. femoral cath stick)? Response Do not include as immunosuppressive therapy. If there is a tumor occlusion? No. If there is an iliac aneurysm? Yes. A 27 year old male patient with treated endocarditis who had a septic emboli stroke a month prior to surgery. Do I code CVD and CVA? A CT scan post op shows old lacunar infarct. Can this be used in the risk section? If not is there any way to document the current infarcts? Code CVA but do not code CVD. No. No, do not code lacunar infarcts as history of CVD or CVA. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 9 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section D SeqNo 552 Field Name RF - CVA Data Specification Indicate whether the patient has a history of stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in cerebral blood supply) that did not resolve within 24 hours. Jan-08 D 554 RF - CVD Rind Oct-08 D 556 RF - CVD NonInvas >79% Jun-08 E 570 Prev CV Intervent May-08 E 620 Prev Oth Card Indicate whether the patient has a history of a Reversible Ischemic Neurologic Deficit (RIND): Patient has a history of loss of neurological function with symptoms at least 24 hours after onset but with complete return of function within 72 hours. Indicate whether the patient has a history of a Non-invasive/invasive carotid test with greater than 79% occlusion. Indicate whether the patient has undergone any previous cardiovascular intervention, either surgical or non-surgical, which may include those done during the current admission. This may include hybrid procedures. Indicate whether the patient had a previous intrapericardial or great vessel procedure performed. Great vessels = aorta, superior vena cava, inferior vena cava, pulmonary arteries and veins. This may include, but is not limited to LVA, acquired VSD, Batista, SVR, TMR, cardiac trauma, pericardial window, cardiac tumor or heart transplant. Question Patient admitted to one hospital with a syncopal episode and workup including Echo shows aortic stenosis, and CT scan of head shows old cerebral infarction. There is no documentation in the H&P or consultations that the patient had any history of a stroke. There is no documentation of any neurological symptoms at all. Can we mark “Yes” to previous stroke just based on testing, with no documentation that the patient ever had a stroke with any neurological symptoms? If the patient has neurologic symptoms that last more than 24 hours but less than 72 hours, do we code both CVA and RIND? Response Yes, the CT is supportive evidence of CVA. Carotid ultrasound documentation of severe high grade or critical stenosis without a percentage provided. Does this meet >79% criteria? Would a REVEAL implant be captured under previous CV interventions? Yes, if there is documentation of severe or critical stenosis. How do we code septal myomectomy? Code as "Previous Other Cardiac". As per the 2.61 Training Manual, this field was included in error and has been discontinued. DO NOT USE THIS FIELD. No, this recording device is not coded as previous CV intervention. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 10 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jun-08 Section E SeqNo 660 Field Name Prev Oth Card PCI May-09 E 671 Prev Oth Card Other Jan-10 Jan-10 Data Specification Indicate whether a previous Percutaneous Cardiac Intervention (PCI) was performed any time prior to this surgical procedure. PCI refers to those treatment procedures that unblock narrowed coronary arteries without performing surgery. PCI may include, but is not limited to: 1. Balloon Catheter Angioplasty, Percutaneous Transluminal Coronary Angioplasty (PTCA). 2. Rotational Atherectomy. 3. Directional Atherectomy. 4. Extraction Atherectomy. 5. Laser Atherectomy. 6. Intracoronary Stent Placement. Indicate whether the patient has undergone any other previous cardiovascular intervention. Question If the PCI was attempted but the wire could not be passed across the lesion should the PCI be coded or should it be coded as OTHER. Response No intervention was performed in either case. Do not code PCI or Other. The STS QA report sets the incidence of cardiac surgery to missing if the risk factor of prior valve = yes. Do we include a history of prior percutaneous valve repairs in the risk factor prior valve? If yes, is this included in determining the incidence of CV surgery? If we are supposed to document prior percutaneous valve surgery in the history but not include the percutaneous repair in determining the incidence of cardiac surgery, please review the DQ report which sets the incidence to null. From QA report: If PrValve = Yes and Incidenc = First CV Surgery then Incidenc is set to missing. Are prior lung transplants captured in section E Previous CV interventions under Prev Other Card Intrapericardial or Great Vessel? If a patient had a prior removal of a subaortic membrane, which was coded as prior sub-aortic stenosis, can it be considered a prior valve Because the intent of the incidence field is to capture surgical interventions, previous percutaneous valve repairs should be captured in “Previous CV Intervention, Other”. Yes, they should be captured as Previous Other Cardiac. Code as Previous Other Cardiac Other. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 11 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Field Name Data Specification Jan-10 June-10 Mar-08 Oct-08 F 751 Previous MI Indicate if the patient has had at least one documented previous myocardial infarction at any time prior to this surgery. An Acute myocardial infarction is evidenced by any of the following: 1. A rise and fall of cardiac biomarkers (preferably troponin) with at least one of the values in the abnormal range for that laboratory [typically above the 99th percentile of the upper reference limit(URL) for normal subjects] together with at least one of the following: a. Ischemic symptoms; b.ECG changes indicative of new ischemia (new ST-T w/changes, new left bundle branch block, or loss of R wave voltage); c. Development of pathological Q waves in 2 or more contiguous leads in the ECG (or equivalent findings for true posterior MI); Question surgery (assume so since it is an option in vlv list) and valve repair since it was subaortic. We kept the custom field of AV Repair so I was not sure if we code as AV Repair. My patient had pectus excavation surgery as a child and now needed a valve replacement. Surgical adhesions made entering the chest difficult. Is there any way to capture this- 1st re-op (even though it was not a previous cardiovascular surgery just sternal)? Can I code this as previous CV intervention - other? The patient had a previous thymectomy with partial sternotomy. The OP note talks about all the adhesions. Should this be considered a previous CV intervention other? The data specification for Previous MI states: Imaging evidence of a region with new loss of viable Myocardium at rest in the absence of non-ischemic cause. This can be manifest in: Echocardiographic, CT, MRI… The Training Manual states: "the current data specifications do not recognize echo as a method of documenting MI." Please clarify. Many times our physicians use the terminology “coronary syndrome”. Without being an expert at reading ECGs, how does one determine if indeed this is a NSTEMI? For example, a patient has chest pain and a small bump in troponin. Response Code as Previous Other Cardiac Other. The patient should be considered a previous CV intervention other if the pericardium was opened during the thymectomy. This Note should be deleted from the Training Manual. It is correct to capture values from Echocardiogram. The example provided would be coded as “Yes” due to the “bump” in troponin. The data definition #1 refers to this rise in troponin. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 12 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Oct-08 F 760 Field Name MI - When Data Specification d. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality; e. Documentation in the medical record of the diagnosis of acute myocardial infarction based on the cardiac biomarker pattern in the absence of any items enumerated in a-d due to conditions that may mask their appearance (e.g., perioperative infarct when the patient cannot report ischemic symptoms; baseline left bundle branch block or ventricular pacing. 2. Development of new pathological Q waves in 2 or more contiguous lead in the ECG, with or without symptoms. 3. Imaging evidence of a region with new loss of viable myocardium at rest in the absence of non-ischemic cause. This can be manifest as: a. echocardiographic, CT, MR, ventriculographic or nuclear imaging evidence of left ventricular thinning or scarring and failure to contract appropriately (i.e., hypokinesis, akinesis, or dyskinesis). b. Fixed (non-reversible perfusion defects on nuclear radioisotope imaging (e.g., MIBI, thallium). 4. Medical records documentation of prior myocardial infarction. Indicate the time period between the last documented myocardial infarction and surgery. 1= <=6 Hrs 2= >6 Hrs but <24 Hrs 3 = 1 to 7 Days 4 = 8 to 21Days 5 = > 21 Days. Question Do you code an MI when from the time the patient c/o symptoms, on ER admission or when it is actually diagnosed with ECG or labs? Response Code the first documentation of the MI diagnoses with ECGs, lab, etc. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 13 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section SeqNo Oct-08 F 770 Oct-08 Oct-08 Oct-08 Oct-08 Field Name Heart Failure Data Specification Indicate whether, within 2 weeks prior to the initial surgical procedure, a physician has diagnosed that the patient is currently in heart failure (HF). HF can be diagnosed based on careful history and physical exam, or by one of the following criteria: 1. Paroxysmal nocturnal dyspnea (PND); 2. Dyspnea on exertion (DOE) due to heart failure; 3. Chest X-ray (CXR) showing pulmonary congestion; 4. Pedal edema or dyspnea, and receiving diuretics; or 5. Pulmonary edema. Question There seems to be a lot of confusion and inconsistency in the coding of this variable. Example: patient has chest pain for 1-2 days and then comes to ER and is diagnosed with ECG/labs. What is the timing of the MI? Do these patients have to be symptomatic? I have physicians that document patient has CHF due to low EF (but no pedal edema, SOB and negative CXR.) Response The timing is the first documentation of MI. What about valve dysfunction and CHF (symptomatic but normal EF), is this coded as CHF? This is very confusing. Can we code “Yes” if patient has a low EF, but no symptoms, no pedal/peripheral edema, and negative CXR? Yes, as the patient is symptomatic. Sometimes they come in with SOB and fatigue and it is noted to be “anginal”, and still have a low EF. Does hypokinesis of the ventricle noted on the cath, help determine decreased LV function a long with the low EF to claim “Yes” for CHF, or does the patient indeed have to be symptomatic, extremity edema, or + on CXR? Can you further clarify this variable? There seems to still be some confusion among data managers re acute CHF vs. History. Yes, the patient is symptomatic. The patient must be symptomatic within 2 weeks of the surgical procedure. This example would not be coded as CHF. No, the patient is not symptomatic. Yes, the patient must be symptomatic. Symptoms within 2 weeks of the date of surgery. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 14 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jan-08 Section F SeqNo 775 Field Name ClassificationNYHA Data Specification Indicate the patient's highest New York Heart Association (NYHA) classification within 2 weeks prior to surgery. NYHA classification represents the overall functional status of the patient in relationship to both heart failure and angina. Choose one of the following: Class I: Patient has cardiac disease but without resulting limitations of ordinary physical activity. Ordinary physical activity (e.g., walking several blocks or climbing stairs) does not cause undue fatigue, palpitations, dyspnea, or anginal pain. Limiting symptoms may occur with marked exertion. Class II: Patient has cardiac disease resulting in slight limitation of ordinary physical activity. Patient is comfortable at rest. Ordinary physical activity such as walking more than two blocks or climbing more than one flight of stairs results in limiting symptoms (e.g., fatigue, palpitations, dyspnea, or anginal pain. Class III: Patient has cardiac disease resulting in marked limitation of physical activity. Patient is comfortable at rest. Less than ordinary physical activity (e.g., walking on to two level blocks or climbing one flight of stairs) causes fatigue, palpitation, dyspnea or anginal pain. Class IV: Patient has dyspnea at rest that increases with any physical activity. Patient has cardiac disease resulting in inability to perform any physical activity without discomfort. Symptoms may be present even at rest. If any physical activity is undertaken, discomfort is increased. Question There is a bolded "Note" in the Training Manual that says not to code NYHA for angina. Is this true? Response Yes, the Training Manual is correct. "Note: The definition in the 2.61 Data Specifications describes NYHA as representing "functional status of the patient in relationship to both heart failure and angina." THIS IS AN ERROR. Please use NYHA for heart failure only, to the fullest extent possible." Furthermore, please disregard the Example provided in the Training Manual (which includes angina.) The "Note" was provided after document review, and the Example as written should have been deleted. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 15 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Apr-08 May-08 Jul-08 Oct-08 Oct-08 Section F SeqNo 791 Field Name Cardiac Presentation on Admission Data Specification Indicate the type of angina present prior to this surgical intervention: Question Must a patient meet all three to qualify for Unstable Angina? 1. No symptoms or angina. 2. Symptoms Unlikely to be Ischemia: pain, pressure of discomfort in the chest, neck or arms not clearly exertional or not otherwise consistent with pain or discomfort of myocardial ischemic origin. This includes patient with non-cardiac pain ( e.g., pulmonary embolism, musculoskeletal, or esophageal discomfort), or cardiac pain not caused by myocardial ischemia (e.g., acute pericarditis). 3. Stable Angina: Angina without a change in frequency or pattern for the six weeks prior to this surgical intervention. Angina is controlled by rest and/ or oral or transcutaneous medications. 4. Unstable Angina: There are three principal presentations of unstable angina:(1.) Rest angina, (2.) New Onset ( less than 2 months) angina, and (3.) Increasing angina (in intensity, duration and/or frequency. If the patient presents with syncope and abdominal pain, negative troponin and normal EKG but the cardiologist thought the syncope was from ischemia and cath showed triple vessel disease; how do I code presentation? 5. Non-ST Elevation MI (Non-STEMI) The patient was hospitalized for a non ST-elevation myocardial infarction as documented in the medical record. Non-STEMIs are characterized by the presence of both criteria: A. Cardiac biomarkers (creatinine kinase-myocardial band, Troponin T or I, and/or myoglobin) exceed the upper limit of normal according to the individual hospital's laboratory parameters with a clinical How would you code for: Patient that comes into the hospital in heart failure, DOE, pedal edema, SOB, no chest pain but hx of severe triple vessel disease and low EF? CAB patients who are diabetic with anginal equivalent symptoms; SOB with or without exertion, should this translate to stable angina? The patient who has AS and presents with syncope is not asymptomatic; they do not have heart failure or angina. How are they coded? How do you capture the patient with fatigue and positive exercise stress test? Patient who goes to primary physician for a check up, has a + stress test, gets cathed and has severe triple vessel disease w/tight left main, abnormal LV and 30% EF; goes to surgery emergently? Only Response No, If the patient meets one of the presentations it can be coded as "Unstable Angina." Symptoms unlikely to be ischemia. Many patients present with symptoms that don't fit the current data specifications for clinical presentation. Some examples include: fatigue, positive exercise stress test or AS with syncope. The specifications are mapped to the ACC by definition and coding. While leaving the field blank is not ideal, when the presentation does not meet the specifications, it is best to leave it blank rather than answer inappropriately. This field can be left blank. It does not fulfill the definition. The next data spec upgrade will address this issue. No symptoms or angina. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 16 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Oct-08 Oct-08 Section SeqNo Field Name Data Specification presentation which is consistent or suggestive of ischemia. ECG changes and/or ischemic symptoms may or may not be present. B. Absence of ECG changes diagnostic of a STEMI (see STEMI). 6. ST Elevation MI (STEMI) The patient presented with a ST elevation myocardial infarction documented in the medical record. STEMIs are characterized by the presence of both criteria: A. ECG evidence of STEMI: New or presumed new ST segment elevation or new left bundle branch block not documented to be resolved within 20 minutes. ST segment elevation is defined by new or presumed new sustained ST segment elevation (0.1mV in magnitude) in two or more contiguous electrocardiogram (ECG) leads. If no exact ST elevation measurement is recorded in the medical chart, physician's written documentation of ST elevation is acceptable. If only one ECG is performed, then the assumption that the ST elevation persisted at least the required 20 minutes is acceptable. Left bundle branch block (LBBB) refers to LBBB that was not known to be old on the initial ECG. For purposes of the Registry, ST elevation in the posterior chest leads (V7 through V9) or ST depression in V1 and V2 demonstrating posterior myocardial infarction is considered a STEMI equivalent and qualifies the patient for reperfusion therapy. Question symptoms of feeling tired and SOB w/minimal exertion. Response Patient who has symptoms of dizziness or syncope, some SOB and gets an Echo showing aortic stenosis? Leave blank for reasons listed in additional Oct 08 response above. A July 08 FAQ appears to be an incomplete response to a question about three distinct examples of patient presentation that need to be coded. In the answer, it seems like there is no solution to the three examples, just a reference to leaving the area blank. While we agree that no answer would be more accurate than an incorrect answer, the FAQ right above this question seems to present a reasonable response to use “symptoms unlikely to be ischemia” for a patient with syncope and abdominal pain. We have a concern that these instances may affect the threshold for data inclusion. Please give more examples of clinical presentations and how they should be coded. Example: when pt presents with SOB. This could be anginal equivalent. It can be appropriate to code symptoms not likely to be ischemia (as in syncope or abdominal pain). This will not affect inclusion. This is an example of CHF, not angina. Please refer to other new postings for additional examples. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 17 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Question What should we code for pain from aortic dissection? Response Symptoms unlikely to be ischemia. Oct-09 Please list the anginal equivalents that we may use. Oct-09 How should presentation be completed for patients with valvular disease? There are no anginal equivalents. Look for clarification in the next data specification upgrade. Leave blank. Oct-09 How should presentation be completed for patients with heart failure, DOE, pedal edema, SOB and no chest pain but a history of triple vessel disease? A patient has an arrhythmia and is cardioverted. Two weeks before surgery the patient is in a normal sinus rhythm and is not on an antiarrhythmic. Do we code yes to seq. #840 and how do we code arrhythmia type in seq. # 851, 852 and 853. Feb-08 Section F SeqNo 840 Field Name Arrhythmia Data Specification B. Cardiac biomarkers (creatinine kinase-myocardial band, Troponin T or I, and/or myoglobin) exceed the upper limit of normal according to the individual hospital's laboratory parameters a clinical presentation which is consistent or suggestive of ischemia. Indicate whether there is a history of preoperative arrhythmia (sustained ventricular tachycardia, ventricular fibrillation, atrial fibrillation, atrial flutter, third degree heart block) that has been treated with any of the following modalities: 1. Ablation therapy 2. AICD 3. Pacemaker 4. Pharmacological treatment 5. Electrocardioversion Heart failure. Code "YES" to Seq# 840 and code "NO" to Seq# 851, 852 and 853. The patient has had a history of arrhythmia but not within two weeks of the primary procedure. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 18 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jan-08 Mar-08 Jun-08 Section G SeqNo 890 Field Name Medi-Beta Blocker Data Specification Indicate whether or not the patient received beta blockers within 24 hours preceding surgery, or if beta blocker was contraindicated or not indicated. The contraindication must be documented in the medical record by a physician, nurse practitioner, or physician assistant. Question What is the difference between Contraindicated and Not Indicated? If I have an order for a Beta Blocker but I cannot find the documentation that it was given, can I code "Yes" because I have an order. What is the difference between Contraindicated and Not Indicated? Response The field "Contraindicated/Not Indicated" is one field. The addition of the verbiage "not indicated" was intended to provide clarification of the intent, however it seems to have caused confusion. As per the Training Manual clarification: "For each medication, check if the medication was not administered or ordered according to the data specification timeframe as documented anywhere in the medical record. If a contraindication is documented explicitly as excluded for medical reasons, or is evidenced clearly within the medical record (notation of a medication allergy prior to arrival), check "Contraindication"/Not Indicated.------Otherwise the answer is "No." Code "NO", this data specification includes a time element, not just an order. "CMS' Coding for Quality: A Handbook for PQRI Participation, March 20, 2008" on page 4 defines: Not Indicated (absence of organ/limb, already received performed); Contraindicated (patient allergic history, potential adverse drug interaction). http://www.cms.hhs.gov/PQRI/Downl oads/2008PQRICodingforQualityHan dbook.pdf NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 19 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Oct-08 Oct-08 Oct-09 Section SeqNo Field Name Data Specification Question Since this field is a PQRI data element, why is our STS data definition different from CMS? This CMS Core measure abstractors have exclusion criteria that the abstractor can code as a contradiction. We don’t unless the contraindication is documented by a physician, PA, or nurse practitioner. Why the difference? If it is an elective surgery, the patient is admitted the same day of surgery, can we use the home medications as preoperative medications? If Beta Blocker, Aspirin, lipid lowering meds, etc. are listed as home medications, but they are not taken “today” for the same day of admitted surgery. Which answer would be check, “No” or “Contraindicated/Not indicated”? Could you please clarify where thrombolytics for acute MI would be noted? This seems to be a pretty significant additional risk factor for bleeding that is not captured. It became apparent many hospitals are not collecting data correctly for medications (3 star rating) once “not indicated and contraindicated” were added as choices making the 3 star rating invalid. Some are using the CMS definition of prior beta blocker. How can we rectify this? Response There is no difference in the definition. Exclusions are being addressed in the new web-based Quality Module for PQRI (Medicare FFS patients). In order to code the home medications you must have documentation of the date and time the patient received the drug. In this scenario, the correct coding is “No”. Preop thrombolytics are not captured in v2.61. Only the number of patients eligible for beta blockers is used in calculating the rating. This is confirmed on audit. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 20 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-09 Section G SeqNo 930 Field Name MedsAnticoagulants Mar-08 G 980 Meds-Steroids Jun-08 G 1021 Meds-ADP Inhibitors Within Five Days Oct-08 G 1023 MedsAntiplatelets Within 5 Days H 1050 Num Dis Vessels Jan-08 Data Specification Indicate whether the patient received IV and/or subq anticoagulants within 48 hours preceding surgery, or if it was contraindicated or not indicated. The contraindication must be documented in the medical record by a physician, nurse practitioner, or physician assistant. Do NOT include Coumadin or one-time boluses of Heparin. Indicate whether the patient was taking steroids within 24 hours of surgery, or if it was contraindicated or not indicated. The contraindication must be documented in the medical record by a physician, nurse practitioner, or physician assistant. This does not include a one time dose related to prophylaxis therapy (i.e., IV dye exposure for cath procedure or surgery pre-induction period). Non-systemic medications are not included in this category (i.e., nasal sprays, topical creams). Indicate whether the patient has received ADP Inhibitors within 5 days preceding surgery, or if it was contraindicated or not indicated. The contraindication must be documented in the medical record by a physician, nurse practitioner, or physician assistant. Indicate whether the patient has received antiplatelets within 5 days preceding surgery, or if it was contraindicated or not indicated. The contraindication must be documented in the medical record by a physician, nurse practitioner, or physician assistant. Indicate the number of diseased major native coronary vessel Question The patient receives Angiomax IV for carotid stenting the day before surgery and an infusion that is completed in the cath lab; should this be counted as anticoagulant within 24 hours of surgery? Response Yes. The data specification for MedsSteroids states: Non-systemic medications are not included in this category. What about Advair? Do not code RF-Immunosuppressive RX for inhalers that are steroidal in form (like Advair.) Is Pletal considered an ADP? No. Is Cilostazol considered an antiplatelet drug? Yes. The patient had a stent to the RCA a few weeks ago with no repeat cardiac Code "None", the artery is considered patent when stented until diagnosed NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 21 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Field Name Data Specification systems; LAD system, Circumflex system, and/or Right system with >=50% narrowing of any vessel preoperatively. Note: Left main disease (>=50%) is counted as TWO vessels (LAD and Circumflex, which may include a Ramus Intermedius). For example, left main and RCA would count as three total. Question catheterization. He is now admitted for elective AVR. Do I assume the patient has no coronary artery disease or do I code one vessel disease? Response with new native disease or in-stent stenosis. Feb 09 NOTE: Clarification to the many questions regarding patients that have had stent placement(s). May-09 If a patient has had a percutaneous coronary intervention (e.g. stent or angioplasty) and the vessel is determined to be patent at the time of the preop cath, is the vessel considered diseased? When a patient comes in with endocarditis or aortic dissection and no cath is done, we leave the fields blank. Is there any way to correct this? Is the left main considered to be diseased if it is anomalous (coming off the right side of the heart) but patent? ONCE a vessel is diseased it is ALWAYS diseased. When coding the number of diseased vessels, capture the number of vessels with either native disease or stents. Once a vessel is diseased it is always diseased - even those vessels that have had previous angioplasty or stent. Oct-09 Jun-08 H 1060 Left Main Dis >=50% Jan-08 H 1070 Hemo Data-EF Done Indicate whether the patient has Left Main Coronary Disease. Left Main Coronary Disease is present when there is >=50% compromise of vessel diameter preoperatively. Indicate whether the Ejection Fraction was measured prior to the induction of anesthesia. Our preop TEEs are done after the induction of anesthesia. If there is no other diagnostic test done, how should we report EF%? In the next data specification upgrade a field will be added for NO CATH. Until that time continue to leave blank. No, there is not stenosis in the left main because of anomalous origin. As per the 2.61 Training Manual, the intraoperative TEE cannot be used to measure EF. Code "No" to Hemo Data-EF done. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 22 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Mar-08 Section H SeqNo 1090 Field Name Hemo Data-EF Method Data Specification Indicate how the Ejection Fraction measurement information was obtained preoperatively. LV Gram: Left Ventriculogram Radionucleotide: Muga Scan Estimate: From other calculations, based upon available clinical data ECHO: Echocardiogram MRI/CT Other Oct-08 Oct-08 Jan-08 Oct-08 Jan-08 H 1100 Hemo Data-HDPA Mean done H 1110 Hemo Data-PA Mean H 1120 VD-StenosisAortic Indicate whether the mean pulmonary artery pressure in mm Hg, was recorded from catheterization data or Swan-Ganz catheter BEFORE the induction of anesthesia. Indicate the mean pulmonary artery pressure in mm Hg, recorded from catheterization data or Swan-Ganz catheter BEFORE the induction of anesthesia. Indicate whether Aortic Stenosis is present. If not documented or not done, indicate as N/A. Question In the Training Manual it states: At the current time, there is no place in the current data specifications to capture the value captured by CT. Does that mean if my patient had a CT angiogram I am not allowed to take the EF from this report? Response This Note should be deleted from the Training Manual. It is correct to capture values from CT. Differentiate selection of LV Gram vs. Estimate: Our EFs are usually performed in the Cath Lab, the Cath Lab usually measures it for the cardiologist. Sometimes the cardiologist uses the terminology, “estimate” and other times not Which data do you use for: Patient has a cath and echo performed within hours or a few days of each other. 1) The echo report notes mitral regurgitation, the dictated cath report states there is none; 2) Which EF result do you use? Our preop TEEs are done after the induction of anesthesia. If there is no other diagnostic test done, how should we report PA mean? Use EF documentation on the LV gram first, if both LV Gram and an Estimate are documented in the medical record. Can you please update the v2.61 FAQs with the formula that can be used to calculate it (sys+dia+dia)/3? The PA mean is not to be calculated. If the PA mean is not recorded, then Seq# 1100 should be coded as “No”. Our preop TEEs are done after the induction of anesthesia. If there is no other diagnostic test done, how should we report Valve Info? As per the Training Manual, the intraoperative TEE cannot be used to diagnose valve disease, Code "N/A" to Seq. Nos. 1120 - 1200. Document the information taken from the diagnostic study done closest to the date and time of surgery. As per the Training Manual, the intraoperative TEE cannot be used to measure EF. Code "No" to Hemo Data-HDPA Mean done. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 23 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section SeqNo H 1130 VD-GradientAortic Oct-08 H 1140 VD-StenosisMitral May-09 H 1180 VD-Insuff-Mitral Oct-09 Field Name Data Specification Indicate the mean gradient across the aortic valve obtained from an echocardiogram or angiogram preoperatively. Indicate whether Mitral Stenosis is present. If not documented of not done, indicate as N/A. Indicate whether there is evidence of Mitral valve regurgitation. Enter level of valve function associated with highest risk (i.e., worst performance). Enter the highest level recorded in the chart. 'Moderately severe" should be coded as "Severe". If data not available or study suboptimal, enter N/A. Question Cath report says “aorta appears normal.” Do you check “No” for aortic stenosis, or does the report specifically have to say no aortic stenosis, in which one would check “N/A”? I just want to be sure that what I have been doing is correct – I have been checking “No”. The answer to this also impacts how one answers/interprets Seq#s 1140-1160. Is there a plan to include valve area instead of mean gradient for patients with aortic stenosis? Response Code N/A, as the valve has not been interrogated by Echo. Echo documents regurgitation of tricuspid and mitral valves with no mention of stenosis. Do you “assume” there is none, or select NA? Can you clarify how to code valve insufficiency? What is the difference between None and N/A? Is insufficiency coded differently for patients undergoing CAB only? Code “None”. It would be coded as “No” only when the valve has been interrogated by Echo, and no stenosis is identified. Valve insufficiency is not coded differently for valve or CAB surgery patients. The amount of insufficiency can be coded on all patients from a ventriculogram or an echocardiogram. Both valve area and gradient will be in the valve module. If there is no ventriculogram or echo documented in the medical record, then the answer is N/A (meaning "not available"). If a ventriculogram or echo result indicates that the result of the test is "normal" and the report does not include any mention of valve function, then the answer is to code as N/A (meaning "not assessed"). "None" would only be coded if a ventriculogram or echo report documents that there was no insufficiency. One cannot assume it is "None" unless it is documented as NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 24 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Nov-08 Section I SeqNo 1222 Field Name Taxpayer Identification Number Data Specification Indicate the group-level Taxpayer Identification Number for the Taxpayer holder of record for the Surgeon’s National Provider Identifier that performed the procedure. Oct-09 Mar-08 Apr-08 May-08 Oct-08 Oct-08 Question My surgeon has a individual TIN and a group TIN, which one am I supposed to use? What are the PROs and CONs to submitting the physicians TIN? I 1230 Incidence Indicate if this is the patient's: -first cardiovascular surgery -first re-op cardiovascular surgery -second re-op cardiovascular surgery -third re-op cardiovascular surgery -fourth or more re-op cardiovascular surgery The patient had a mitral valve balloon valvuloplasty in 1980, a mitral valve repair in 1992 and is now admitted for mitral valve replacement. Do I code the balloon valvuloplasty as the first CV intervention? What is the incidence of the mitral valve replacement? The patient with prior percutaneous ASD closure is now admitted for planned CAB, does this get counted as first CV surgery or first re-op CV surgery? Please explain why a percutaneous valvuloplasty is considered a first CV intervention and a percutaneous repair is not. What procedures should be included? The Training Manual says “any procedure to the heart or great vessels.” Do we count percutaneous coronary or valve procedures? Minimally invasive coronary procedures that are off pump and done via thoracoscopy or robotics? Response such. Remember the old adage: "If it isn't documented, it wasn't done." During the next upgrade, the definition of "N/A" will be addressed. Enter the TIN used to bill for physician services. Please check with the surgeon’s billing office (or hospital billing department when appropriate) to determine. This field is related to PQRI and will identify which surgeons will get paid and which will not. If your site is not participating in PQRI, you can leave the field blank. The mitral valve replacement is the "Second Re-Op Cardiovascular Surgery". The first CV surgery was the balloon valvuloplasty, the first reop was the mitral repair. This is the patient's first CV surgery. The incidence for both ASD and percutaneous balloon valvuloplasty that did not entail an incision should NOT be coded as REOP. No. Percutaneous procedures do not alter the incidence of the surgery. These procedures are surgical cases and should be captured when coding surgical incidence. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 25 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Question Aortofemoral bypass? Response Do not include Aorto-femoral bypass when coding surgical interventions. Oct-08 Is a sternotomy required for a procedure to be counted? Oct-09 What is the correct incidence if the patient has had a previous percutaneous valvuloplasty but no prior CV surgery? No, procedures can be done through a thorocotomy or thorocoscopically, for example. The incidence is First CV surgery, however, the previous percutaneous valvuloplasty must be coded as Previous Other in sequence number 671. Code Urgent, and Coronary Anatomy for urgent reason. Oct-08 Oct-08 Oct-08 Oct-08 Section I SeqNo 1240 Field Name Status Data Specification Indicate the clinical status of the patient prior to entering the operating room: Elective: The patient's cardiac function has been stable in the days or weeks prior to the operation. The procedure could be deferred without increased risk of compromised cardiac outcome. Urgent: Procedure required during same hospitalization in order to minimize chance of further clinical deterioration. Examples include but are not limited to: Worsening, sudden chest pain, CHF, acute myocardial infarction (AMI), anatomy, IABP, unstable angina (USA) with intravenous (IV) nitroglycerin (NTG) or rest angina. Emergent: Patients requiring emergency operations will have ongoing, refractory (difficult, complicated, and/or unmanageable) unrelenting cardiac compromise, with or without hemodynamic instability, and not responsive to any form of therapy except cardiac surgery and emergency operation is one in which there should be no delay in providing operative intervention. The patient's clinical status includes any of the following: a. Ischemic dysfunctions (any of the following): (1) Ongoing ischemia Please give additional information on how to determine Elective status. If a patient is admitted electively for open heart surgery, that is obviously elective. For patients who wait a few days (i.e., over the weekend) after discontinuing Plavix or for other reasons, sometimes it is difficult to determine whether the procedure could be deferred without increased risk of compromised cardiac outcome. On occasion we use Emergent as an operative status, but sometimes the options that we are given to choose for “reasons” do not fit. Should we leave this blank if nothing fits? Please provide better differentiation between Elective and Urgent criteria (e.g., pts who come in for elective cath, find left main disease, they are put in the ICU from the Cath Lab, however they receive only cardiac monitoring, or simply pts for elective CABG with left main disease). Give examples of when IABP would be the reason for Urgent criteria: At our facilities it is inserted most often as a prophylactic measure (especially if patient has a very low EF, otherwise it is for hemodynamic instability). Yes, if nothing fits you may leave the field blank. The next data spec upgrade will address this issue. Code Urgent, and Coronary Anatomy for urgent reason in the example provided. As mentioned above, the next upgrade will address these issues. IABP is an Urgent reason and can be coded as such. A patient with unstable angina that could not be discharged prior to surgery would be an example. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 26 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Feb-10 June-10 June-10 June-10 Section SeqNo Field Name Data Specification including rest angina despite maximal medical therapy(medical and/or IABP); (2) Acute Evolving Myocardial Infarction within 24 hours before surgery; or (3) Pulmonary edema requiring intubation. b. Mechanical dysfunction (either of the following): (1) shock with circulatory support; or (2) shock without circulatory support. Emergent Salvage: The patient is undergoing CPR en route to the OR or prior to anesthesia induction. Question Should the following cases be coded elective or urgent? 1. pt hx of gi bleed, brought in 1 day early for poss transfusion, h&h ok, decided to keep and hydrate, cabg next day. 2. pt found to have mass in stomach on ugi; admitted 1 day early for egd, admitted to cvu for follow up labs based on previous anemia, cabg next day. 3. pt hx of arf, chf in 9/09, cathed on 10/05 and found to have severe mr w/pulm htn. Brought in 11/09,swan and a-line placed, nipride started to see if pulm htn improved. Taken to surgery 11/11. 4. pt with elevated A1C, brought in for insulin gtt day before surgery Should a patient with ruptured aortic dissection be considered salvage? CPR was not being performed. The patient was initially admitted for CAB/Valve. The pre-op x-ray showed a lung mass so the OH surgery was delayed until mediastinoscopy could be done. During the mediastinoscopy, there was an inadvertent injury to a major vascular structure necessitating sternotomy. The mediastinal lymph node was negative for cancer so the surgeon decided to proceed with the CAB/Valve, what is the status and how do you capture the OR times and incision times? The patient was taken to the OR emergently for removal of a freely mobile mass/thrombus in the left ventricle and the risk of embolic stroke. None of the emergent reasons fit. How should emergent Response Each of these cases should be coded as elective. No, this is an emergent case. The CAB/Valve procedure should be coded as elective. Code the time of entry and incision time for the mediastinoscopy. Leave emergent reason blank. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 27 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Mar-08 I 1250 Field Name Urgent Reason Data Specification Question reason be coded? Response How do we capture urgent reason for patients with endocarditis? Code "Valve Dysfunction." May-09 The Urgent Reason for surgery, AMI, does not include a definition specifying the time frame between acute MI and start of surgery. The DQR report includes a data consistency check for when the urgent reason is acute MI and the timing of the MI is > 7 days. Can the STS include a definition for the urgent reason AMI as there are clinical situations where a patient is > 7 days post AMI and still waiting for surgery? If the patient remains in the hospital longer than 7 days before surgery post AMI, it is appropriate to code “Urgent Reason” as “AMI”. The data quality report (DQR) will continue to report that urgent reason as a quality check, just to be sure that is what was intended by the data manager (because 7 days is outside the usual range.) Oct-09 Does severe Left Main / Critical (80%) stenosis qualify for urgent status and should the urgent reason be Anatomy? The patient is admitted with AMI and due to other medical conditions the physician feels the need to stabilize. AMI is now 8-21 days form the date of surgery. The DQR questions the choice of AMI for the urgent reason. What Is the correct urgent reason? Yes, code anatomy. Oct-09 Indicate which one of the following applies as the reason why the patient had Urgent status: Acute myocardial infarction (AMI) Intra-Aortic Balloon Pump (IABP) Worsening, sudden chest pain Congestive Heart Failure (CHF) Coronary Anatomy Unstable angina (USA) with intravenous (IV) nitroglycerin (NTG) Rest angina Valve Dysfunction - Acute Native or Prosthetic Aortic Dissection Angiographic Accident Cardiac Trauma AMI, the data quality check is just asking you if you are sure the AMI is the valid data for the field. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 28 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-09 Section SeqNo Field Name Data Specification Oct-09 Oct-09 I 1260 Emergent Reason Patients requiring emergency operations will have ongoing, refractory (difficult, complicated, and/or unmanageable) unrelenting cardiac compromise, with or without hemodynamic instability, and not responsive to any form of therapy except cardiac surgery. An emergency operation is one in which there should be no delay in providing operative intervention. Indicate which one of the following applies as the reason why the patient had Emergent Status: (Select one): Shock with circulatory support. Shock without circulatory support. Pulmonary edema requiring intubation. Acute Evolving Myocardial Infarction within 24 hours before surgery. Ongoing ischemia including rest angina despite maximal medical therapy. Valve Dysfunction - Acute Native or Prosthetic. Aortic Dissection. Angiographic Accident. Cardiac Trauma. Question Would NSTEMI qualify as AMI under urgent reason? Is there a priority for the urgent / emergent reasons? AMI, IABP, Worsening chest pain, etc. Is there a priority for the urgent / emergent reasons? AMI, IABP, Worsening chest pain, etc. Response Yes. No, choose the most appropriate reason. AMI and IABP are in the risk models. None of the urgent / emergent reasons is in the risk models. No, choose the most appropriate reason. AMI and IABP are in the risk models. None of the urgent / emergent reasons is in the risk models. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 29 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Oct-08 Sept-09 Oct-09 Apr-10 Section I SeqNo 1280 Field Name CAB Data Specification Indicate whether coronary artery bypass grafting was done. Question Should reconstruction for mechanical reasons (e.g., reimplantation during an aortic root reconstruction or related to a congenital abnormality) of either the coronary artery ostium or body of the coronary artery, be counted as a CAB? I would propose that it should not. The history, risk factors, and outcomes are completely different than the CAB population for CAD. Lumping these patients into the CAB group does not make sense from a risk-modeling standpoint. They do have risk, but it is not from the same factors that are captured in the CADCAB population. If not CAB, then where should we capture these procedures? The patient has an aortic dissection, does not have a cardiac cath, goes to surgery for AVR, replacement of the ascending aorta with tube graft and saphenous vein graft to the RCA. How do I code for the saphenous vein graft? What category does CAB / TMR fall into? Is this captured as an isolated CAB? Pt came in to ER in severe distress. CT angio of chest showed ruptured RCA graft with active hemorrhage in to the pericardium and mediastinum. Pt went emergently to surgery. He had a Repair of the right coronary artery bypass graft aneurysm and a CABG x1 to the RCA. Do I count this as a CABG + other or as an Isolated CABG? Response No. This is not a CAB and should not be coded as such. These examples are actually part of the procedure itself. They are not captured in Other procedures as they are part of the primary procedure. Code yes to seq. no. 1280 and code 1 in seq. no. 1530 for number of distal anastomoses with venous conduit. CAB + Other. Code the case as CAB. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 30 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Dec-08 Section I SeqNo 1290 June-10 I Oct-08 I Oct-08 May-09 Feb-10 Feb-10 Field Name OpValve Data Specification Indicate whether a surgical procedure was done on the Aortic, Mitral, Tricuspid or Pulmonic valves. 1300 VAD 1310 Other Card Indicate whether a ventricular assist device (VAD) was implanted. Indicate whether another cardiac procedure was done (other than CAB and/or Valve procedures). Question A mitral valve replacement via a thoracotomy approach during the cannulation damage was done to the iliac vein causing bleeding that required the trauma team to explore the abdomen. The repair was done during the initial procedure and the abdomen was packed. The following day the patient returned to the OR for ileostomy. The patient had further complications from the surgery. Should this be coded as isolated Valve or Valve plus Other? Should an unplanned VAD be included in the complications section? Angiographic accident: Where would this be placed within the other operative categories? Seq# 2430 Cardiac Trauma? Shouldn’t Angiographic accident have its own category? Can we still submit data if it is a stand-alone only, and not done with a major heart surgery and/or great vessels? Will it be benchmarked or just thrown in the “Other” category (i.e., lobectomy by a cardiac surgeon, lung transplant)? The procedure ascending aorta plus AVR is captured as a valve procedure. Should the ascending aorta also be captured as an “other cardiac procedure” with the corresponding aorta questions answered? If a patient had an Imbrication of the LV because of an anuerysm that was too small to resect, do I code this as other cardiac? Do I combine these two consecutive planned surgeries, same day, on a trauma patient? 1st op on 11/11/09 Response This should be coded as an isolated valve. This intraoperative complication and resultant procedures are complications of the primary procedure. Intraoperative complications and subsequent procedures used to treat those complications do not change the intended coding of the procedure. Not at this time, capture the unplanned VAD in the VAD section. An angiographic accident is not coded. Do not code as Other. No, these procedures should be captured in the General Thoracic database if applicable to the surgeon performing these types of procedures. Capture the procedures related to the ascending aorta as “Other Cardiac Other”. Yes, code other cardiac procedure, LVA. Code only one procedure. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 31 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Field Name Data Specification June-10 Dec-08 I 1320 Other Non Card Indicate whether a non-cardiac procedure was done. May-09 July-09 Jan-08 Oct-08 I 1321 CPT-1 Code #1 Indicate the first CPT procedure code (CPT-1) pertaining to the surgery for which the data collection form was initiated. Question 1030-1330 for Thoracic endovascular stenting, then 2nd op on 11/11/09 1330-1930 moved to other OR for brachiocephalic trunk removal and reconstruction w/graft We exposed the distal RCA to the PDA which was heavily calcified. We opened the artery & had to endarterectomize. We used saphenous vein graft to construct in end-to-side fashion and then clip the vein superiorly to allow good roof and a patch angioplasty of the junction. Should this be coded as other? Esophagoscopy/TEE and CAB is performed should this be coded as CAB or CAB plus Other? A patient had an isolated aortoinnominate and aortocommon carotid bypass. Is this coded as Other Cardiac or Other non cardiac? Should this case be included in the Adult Cardiac Database? A patient had an isolated aortoinnominate and aortocommon carotid bypass. Is this coded as Other Cardiac or Other non cardiac? Should this case be included in the Adult Cardiac Database? What should I do if a patient has surgery and the CPT code I am given is not on the list of CPT codes in the Training Manual (which is the same list that is on the STS Web site)? Could you please clarify when to use one of the CPT codes on the list? Is this going to be expanded? Response No, this is isolated CAB. This should be coded as isolated CAB. Code Other Non-Cardiac in seq 1320 and in seq 2580 Other Non-Cardiac Vasc. Code Other Non-Cardiac in seq 1320 and in seq 2580 Other Non-Cardiac Vasc. Do not enter any CPT code that is not on the list. Use these CPT codes for any applicable surgery. The list of CPT codes will continue to be expanded as appropriate. Three (3) codes are planned to be added in December 2008. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 32 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Sept. 2009 Section SeqNo Mar-10 I 1336 Field Name OR Exit Date and Time Data Specification Indicate the date and time, to the nearest minute (using 24-hour clock), that the patient exits the operating room. If the procedure was performed in a location other than the OR, record the time when the sterile filed, or its equivalent, was taken down. Question If the only procedure is pericardial window should I capture the CPT code 33025? Patient was admitted to the OR for a CABG x1, VSD closure, Restore procedure of the right ventricle, implant and explantation of RVAD, closure of PFO/AST. Post procedure the chest was left open and the patient remained in the OR overnight under ICU staff care. The patient eventually went into full organ failure and died in the OR after this procedure. 1) How do I count the procedure (OR)/ICU time? 2) Hemodynamically going into the procedure the patient was on IABP, CI: 2.3-2.5 pre-op and SBP>80. The IABP was in place 24 hrs prior to the procedure due to hypotension during cardiac catheterization, does this count for cardiogenic shock? 3) Does the death get coded as an OR death during the initial procedure. Response Do not include pericardial windows in the adult cardiac database. Capture the end of surgery and OR exit time as the time the dressings were applied. Capture the remainder of the time as ICU hours. The patient was not in cardiogenic shock at the time of surgery. Code the death in the ICU. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 33 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jan-08 Oct-09 Section I SeqNo 1337 Field Name Initial Intubation Date and Time I 1338 Initial Extubation Date and Time Data Specification Indicate the date (mm/dd/yyyy) and time (hh:mm)(24 hour clock) ventilatory support started. The following guidelines apply: 1.Capture the intubation closest to the surgical start time. If the patient intubated upon admission and remained intubated until the surgical start time, capture this intubation's date and time. 2. If the patient was admitted intubated (intubated at another institution) and remained continually intubated until the surgical start time, capture the patient's admission date and time. 3. If the patient was admitted with a tracheostomy in place without ventilatory support, capture the date and time closest to the surgical start time that ventilatory support was initiated. 4. If the patient was admitted with tracheostomy in place receiving chronic ventilatory support, capture the admission date and time. 5. If the intubation date and time is otherwise unknown, enter the date and time the patient entered the operating room. 6. Do not alter the previously established date and time that ventilatory support was initiated for scenarios including, but not limited to, interruptions in ventilatory support due to accidental extubations/decannulation, elective tube change etc. Indicate the date (mm/dd/yyyy) and time (hh:mm)(24 hour clock) ventilatory support initially ceased after surgery. The following guidelines apply: Question Why is the STS interested in capturing intubation time? Response Those timed events asked for by STS Nomenclature and Coding committee are actually used for RUC-related discussions/negotiations to try to optimize reimbursement by assigning appropriate value to various essential portions of the surgery. Information regarding RUC can be located on the Web using the following URL: http://www.amaassn.org/ama/pub/category/16401.ht ml Are the hours the patient is on CPAP included in the initial ventilation time? As long as the patient has an endotracheal tube or tracheostomy tube that is connected to the respirator for CPAP, the hours are still captured. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 34 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Mar-08 I 1345 Oct-08 Oct-08 Oct-08 Field Name Antibiotic Selection Data Specification 1. Capture the extubation closest to the surgical stop time. 2. If the patient has a tracheostomy and is separated from the mechanical ventilator postoperatively within the hospital admission, capture the date and time of separation from the mechanical ventilator closest to the surgical stop time. 3. If the patient expires while intubated or cannulated and on the ventilator, capture the date and time of expiration. 4. If the patient is discharged on chronic ventilatory support, capture the date and time of discharge. Indicate if there was documentation of an order for a first generation or second generation cephalosporin prophylactic antibiotic or documentation that it was given preoperatively. Question This field does not seem to allow for Vancomycin to be a choice. Is the intent of the field to determine whether the patient received the appropriate antibiotic? Can we count/how do we count Levaquin as a pre-op antibiotic since it is not a cephalosporin or Vancomycin? A patient with active endocarditis is on antibiotics prior to surgery and continued post-op, but may not be on a first or second generation cephalosporin, and so the patient does not get credit for the right antibiotic selection? Please clarify when patient has a documented allergy. The FAQ’s state to code “No”. But I went to a regional meeting and they said if Vanco (for Response The intent of the field is only to determine whether the patient received a first or second generation cephalosporin or had an order written to receive a first or second generation cephalosporin. This is a PQRI field that is related only to the order for, or receipt of, these two specific categories of antibiotics. The order itself constitutes compliance with this definition. No, do not code any other antibiotic other than first generation or second generation cephalosporin. When the patient is being treated appropriately with another antibiotic, he is not getting a cephalosporin per the data definition (but is still getting appropriate treatment). The question is still answered “No” as the patient is not getting a cephalosporin. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 35 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Field Name Data Specification Oct-08 Oct-08 I 1346 Antibiotic Timing Indicate whether prophylactic antibiotics were ordered OR given within one hour of surgical incision (two Hours if receiving vancomycin or fluoroquinolone). The surgical incision time is the time of the first incision, regardless of location. Question example) is used when pt has an allergy, then that would be the appropriate antibiotic The FAQ seems incomplete. In both the full data specs and the Training Manual, a two hour window is noted to be acceptable for Vancomycin, but only cephalosporins are to be used for Seq#1345. Does this mean that if the patient is allergic to cephalosporin, and Vancomycin is order, we would use “No” for Seq#1345, and “Yes” for Seq#1346, if the two hour time is enforced? Those who participate in PQRI are aware of modifiers used for that project. It would seem most sensible that the STS would have used the same. This is a PQRI data element. Why would our surgical infection prevention measures be different in definition and coding from CMS? STS definition allows for compliance if the order is written where CMS does not take the order as compliance. Why the difference? This is a preliminary to the PQRI that will be expanded to the Beta Blocker and IMA also. These will have exceptions that will need to be clarified to match the project as it stands now. I feel there will be lots of questions concerning this. Response The v2.61 data specs do not have modifiers. The new Quality Module will include exclusions to capture for Medicare FFS patients being submitted for PQRI. The STS definition is the same as CMS. The v2.61 data specs do not include CMS exclusions. Exclusions will be addressed for PQRI documentation for CMS Measures 43-45 in the new Quality Module for PQRI (Medicare FFS patients). NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 36 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Mar-08 May-08 Oct-08 Oct-08 Section I SeqNo 1347 Field Name Antibiotics Discontinued Data Specification Indicate whether the prophylactic antibiotics were ordered to be discontinued OR were discontinued within 48 hours after surgery end time. Determine the timeframe (within 48 hours) begins at the "surgical end time"-the time the patient leaves the operating room. Question If the patient has significant drainage from the chest tubes, our physicians will continue antibiotics until they are removed. All the initially ordered doses were given within the time frame required by the element, but continuing them makes it appear differently. How do I resolve this? If the patient dies in the operating room during the primary procedure, how do we code antibiotic discontinued? If an antibiotic is given pre-op within one hour of cut, but no doses are given post-op, does this count for discontinued within 48 hours post-op? Patient has a suspected infection and antibiotics are started in and continued in and beyond the 48 hr window. The termination of the prophylactic dosing for the surgery was completed within 48 hrs. You answer “yes” or “no” to discontinuation? Also, if you refer to PQRI definitions and possible inpatient CMS measures in the future, will the STS Web site please consider either posting the necessary information to mirror the other organization’s definitions, or provide a direct link to the necessary information? This would be most helpful. Response The intent of the field is to capture whether prophylactic antibiotics were actually discontinued within 48 hours from surgery end time or an order was written for the antibiotics to be discontinued at a time that was 48 hours or less from the end of surgery. This is a PQRI field. If the order was written that they be discontinued as per the data definition, and the patient continued to receive antibiotics, the answer is "Yes" -- the order was written. The order itself constitutes compliance with this data definition. Code "Yes". Code “Yes”. Yes, you can code “Yes” to discontinuation of ABX. CMS measures and their definitions, exclusions, etc. can be located on the CMS Web site. Go to www.cms.hhs.gov/PQRI, and look under “PQRI Tool Kit” for the Coding for Quality Handbook. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 37 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jan-08 Section I SeqNo 1350 Field Name CPB Utilization Jun-08 I 1382 Circulatory Arrest Time Feb-10 I 1400 Aortic Occlusion Data Specification Indicate the level of CPB or coronary perfusion used during the procedure: None = no CPB or coronary perfusion used during the procedure. Combination = with or without CPB and/or with or without coronary perfusion at any time during the procedure (capture conversions from off-pump to on-pump only): At the start of procedure: No CPB/No Coronary Perfusion->conversion to -> CPB At the start of procedure: No CPB/No Coronary Perfusion -> conversion to > Coronary perfusion At the start of procedure: No CPB/No Coronary Perfusion -> Conversion to coronary perfusion -. conversion to -> CPB Full = CPB or Coronary perfusion was used for the entire procedure. Indicate the total circulatory arrest time in minutes. Circulatory arrest time is recorded in the perfusion record or operative record and indicates the time the patient was not supported by circulation. Indicate the highest level of aortic occlusion used. 1 = None 2 = Aortic Crossclamp 3 = Balloon Occlusion 4 = Partial Crossclamp Question Please clarify combination CPB Utilization. If the surgeon schedules all of his cases off pump, but once the chest is open that's when he decides if the pt will go on pump. Would all of his cases be coded as combination CPB Utilization, if so is it coded as planned or unplanned? Response The procedure was done with Full CPB. Your surgeon identifies the intent to do the entire procedure onpump. The database only allows up to 100 minutes for circulatory arrest time. What should we enter when it takes longer than 100 minutes? Enter the maximum number allowed by the database. For surgeries involving "Replacement of the Descending Aorta" surgeon dictates "cross clamp placed just above aortic cannula in chest & second clamp placed distal to (L) subclavian artery". My understanding is that this particular placement of cross clamps for DTA surgeries is more specific to lower body nonperfusion vs. cardiac non-perfusion. Is Sequence 1400 related specifically to CARDIAC non-perfusion or should the lower body non-perfusion cross clamp times be captured here as well? Capture the cross clamp times for cases involving the descending aorta. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 38 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section I SeqNo 1426 I 1450 IABP Indication Jan-10 I 1490 Intraop Blood Products-Cryo Units Dec-09 J 1530 Distal Anast - Vein # Jan-08 J 1531 Dist Anast - Vein Harvest Technique Oct-09 Oct-09 Field Name Cerebral Oximeter Provided the First Indication Data Specification Indicate whether the cerebral oximeter provided the first indication of a technical problem or physiological change in the patient that could potentially lead to an adverse patient outcome. Indicate the primary reason for inserting the IABP. Choose one of the following: Hemodynamic Instability PTCA Support Unstable Angina Cardiopulmonary bypass (CPB) weaning failure Prophylactic Indicate the number of units of cryoprecipitate that were transfused intraoperatively. One bag of cryo = one unit. The number of units is not volume dependent. Indicate the total number of distal anastomoses with venous conduits. Indicate the technique used to harvest the vein graft(s). 1 = Endovascular 2 = Direct vision 3 = Combination Question Is it necessary to indicate the cerebral oximeter provided first indication? Response Yes, when documented. Please note this is an Optional field for harvesting. An IABP is inserted in the cath lab for pulmonary edema. The patient is not in shock, the BP is normal or high, there is no chest pain. It seems the only category they can fall into is prophylactic but that doesn’t seem appropriate. What should the reason be If the cath report says CHF? Hemodynamic instability. Remember that BP is not the only hemodynamic pressure that can be an indication of instability. Should we count all cryo used intraoperatively even if the perfusionist documents "not transfused, used to prep VAD"? Yes, include the cryoprecipitate used to prep the VAD. The surgeon performs an endarterectomy of the LAD and anastomosed a diamond shaped segment of sapheonous vein to the LAD, then the LIMA is anastomosed to the vein patch in an end to side anastomosis. Is the vein patch considered a SVG and then is the graft considered a distal vein graft? If the PA begins to harvest the vein using endovascular technique and then switches to direct vision, how should this be coded? Code the IMA as a one distal arterial graft. The vein patch angioplasty does not alter the coding. The patient has vein harvested both open and endoscopically. Should we capture both times if only one vein is used. Code "Combination" to include both techniques. Count the total time in minutes, include both the endoscopic and open harvest times. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 39 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jan-08 Section J SeqNo 1532 Field Name Saphenous Vein Harvest Time Data Specification Indicate the total time in minutes for saphenous vein harvest. Jan-08 Question If the PA harvesting vein has to go to the chest to help the surgeon and then returns to complete the vein harvest, will the prolonged harvest time be counted against the PA? How is the harvest time coded? Response No, the prolonged harvest time will not count against the PA. As per the 2.61 Training Manual, Harvest time is coded from skin incision until the vein is out of the leg. Harvest time is coded when all the vein is out of both legs. Jan-08 If vein is harvested from both legs, how is harvest time coded? Apr-08 The database only allows up to 99 minutes for saphenous harvest time. What should we enter when it takes longer than 99 minutes? If the saphenous vein is harvested and not used, do we still code the harvest time? Enter the maximum number allowed which is "99." Does harvest time have to be recorded in the medical record for purposes of the audit? Is this the time the vein/artery is “out” or “useable”? We have been recording time of incision to the time when the vein/artery is “useable” as a conduit (after side branches tied or clipped and prepped). Would you clarify how to handle a distal vein conduit harvest from BOTH lower legs? Do we add the times together for both harvests? Is this incision to closure or incision to “vein out”? All other requested times include closure. If the saphenous vein is harvested and not used, do we still code the harvest time? Would a Passport device be considered an anastomotic device? Yes. May-08 May-08 Oct-08 Oct-08 Oct-08 Jan 09 Jan 09 J 1540 Anastomotic Device Used Indicate whether an anastomotic device/material was used for proximal or distal anastomoses such as glue, magnets, clips, stapler, etc. Excludes sutures. Yes. Incorrect. Please see correction dated Jan-09. Code when the vein/artery is out of the leg. Add the cumulative time. Incision to vein out of the leg. Correcting the FAQ from May 08. Do not include/code the harvest time when the saphenous vein is not used. Yes, this is an anastomotic device. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 40 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section J SeqNo 1550 Oct-08 J 1560 Field Name Anastomotic Device IMA Artery Used Data Specification Indicate which type of anastomotic device was used. If more than one device used, indicate device used on Distal Anastomosis. Indicate which, if any, Internal Mammary Artery(ies)(IMA) used for grafts. Oct-09 Jan-08 J 1602 Radial Artery Harvest Time Indicate the total time in minutes for radial artery harvesting. Dec-08 K 1630 VS-Aortic ProcProcedure Indicate whether a surgical procedure was done or not none on the Aortic Valve. Select one of the following: a. No b. Replacement c. Repair/Reconstruction d. Root Reconstruction with Valve Conduit e. Replacement + Aortic Graft Conduit (not a valve conduit) f. Root Reconstruction w/Valve Sparing g. Resuspension Aortic Valve with Replacement of Ascending aorta h. Resuspension Aortic Valve without Replacement of Ascending aorta i. Resection Sub-Aortic Stenosis Jan-10 Jan-10 Question Does this include Anastomotic assist devices such as Guidant Heart String or Novare Enclose II? Response No, Guidant Heart Strings or Novare Enclose devices are not anastomotic devices. Instead of only a “Yes” or “No” choice for IMA use for CABG, will there ever be criteria that is accepted so we could use the choice of being contraindicated? Sometimes you really cannot use the IMA and with this choice the results would not be indicated as a negative in the quality outcomes. Is it possible to have a contraindication if the patient has a competitive flow issue or stenosis in the vessel? Is radiation to the chest wall a contraindication for use of the IMA? How is the harvest time coded? This will be addressed in the new Quality Module for PQRI (Medicare FFS patients). Should Tongue graft or Mini roots be coded as valve sparing? Should we collect data on Valve repair where the Cardiologist with Surgeon assist, uses an Amplatz valve device? Aortotomy and exploration of prosthetic aortic valve and aortic root prosthesis. Was the aortic root repaired or just explored? The aortic graft was transected and the aortic root and mechanical aortic valve were inspected. After inspection the aorta and aortic root were closed. No repairs were made. Contraindications are included in the PQRI data collection only. Harvest time is coded from skin incision until the artery is out of the arm. Yes. These are valve sparing procedures. Yes, include these procedures in the database. Code as Other Cardiac Other NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 41 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jun-08 Section K SeqNo 1640 Field Name VS-Mitral ProcProcedure Data Specification Indicate whether a surgical procedure was done or not none on the Mitral Valve. Select one of the following: a. No b. Annuloplasty only c. Replacement d. Reconstruction with Annuloplasty e. Reconstruction without Annuloplasty Sep-08 Feb-08 K 1690 VS-Aortic ProcImp Indicate the name of the prosthesis implanted. Oct-08 Sep-08 K 1740 VS-Mitral ProcImp-Type Oct-08 K 1881 Valve Implant List Version Number Indicate the type of implant; choose one: M = Mechanical B = Bioprosthesis H = Homograft A = Autograft (Ross) R = Ring/Annuloplasty BA = Band/Annuloplasty The version number of the list of valve implant options. The value is inserted into the record at the time the record is created. The version numbers will be specified by the STS. Question A growth was removed from the leaflets of the mitral valve. No ring, band or suture was used. How is this coded? Response Code as "Reconstruction without annuloplasty". If a Myocor Coapsys Device is placed, is that coded as annuloplasty only? No, code Myocor Coapsys device as Other Cardiac Other in sequence number 2560. For Valved conduits not listed in the valve key, is it correct to code Other? When you are selecting a valve implant, is it correct that a CarpentierEdwards Perimount Pericardial Bioprosthesis B22 would be chosen for the Aortic model #2700, as well as the Mitral model #6900P (Plus)? Yes, valves not listed are coded "Other" 777. When the valve is not listed on the current list, code Other=777. Does Myocor Coapsys device get coded as Other 777? Please note that the Valve list will be updated annually in January of each year and will be provided to vendors for uploading into participants’ software. No, this device is not coded as an implant in the annulus of the mitral valve. Are there any updates to download for STS Valve placement? Some devices used at our hospital do not show up in the drop-down for valve devices. This list will be updated annually in January and provided to vendors for uploading into the software. Can I manually add the device? You may choose to add site-specific custom fields, but they will not be harvested. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 42 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date May-09 Section L SeqNo 1930 Field Name VAD-Indication for Initial VAD Data Specification Indicate the reason the patient is receiving the initial ventricular assist device (VAD). -Bridge to transplantation: includes those patients who are supported with a VAD until a heart transplant is possible. -Bridge to Recovery: Includes those patients who are expected to have ventricular recovery. )i.e.Myocarditis patients, postcardiotomy syndromes, viral cardiomyopathies, AMI w/ revascularizatin, and post-transplant reperfusin injury). -Destination: includes those patients where a heart transplant is not an option. The VAD is place from permanent life sustaining support. -Postcardiotomy Ventricular failure (separation from CPB): includes those patients who receive a VAD because of failure to separate form the heart-lung machine. -Postcardiotomy refers to those patients with the inability to wean from cardiopulmonary bypass secondary to left, right, or biventricular failure. -Device Malfunction: Includes those patients who are currently VAD supported and are experiencing Device failure. -End of Life: Mechanical Device pump had reached functional Life expectancy and require replacement. Question Is there a place to capture the preop risk factor of Impella’s and PVAD’s? Response No, not in the v2.61 data specifications. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 43 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section Oct-08 L SeqNo 2060 Field Name VAD-Explant Data Specification Indicate if the VAD was explanted. Explant is defined as physical removal of the VAD. M 2380 Other Card-ASD May-09 M 2450 Other CardArrhythmia Correction Surgery Oct-09 M 2470 Other Card-Atrial Fibrillation Correction Surgery Indicate whether the patient had an Atrial Septal Defect Repair either in conjunction with, or as the primary surgical procedure including but not limited to ASD, Secundum; ASD, Sinus venous; and PFO. Indicate if one of the following arrhythmia correction devices was surgically placed either in conjunction with, or as the primary surgical procedure: None Permanent Pacemaker: an internal electronic generator that controls the heart rate. Permanent Pacemaker with Cardiac Resynchronization Therapy (CRT): an internal permanent pacemaker that uses biventricular electrical stimulation to synchronize ventricular contraction. Automatic Implanted Cardioverter Defibrillator (AICD): an internal device that defibrillates the heart. AICD with CRT: an internal AICD that uses biventricular electrical stimulation to synchronize ventricular contraction. Indicate if one of the following atrial fibrillation correction surgeryies was performed with in conjunction with, or as the primary surgical procedure. the intent of both surgeries is to preclude the atria from fibirllating by Oct-09 Question Patient was transferred after implant to another hospital out of state for continued care and possible transplant. Due to a clot formation, the VAD was removed. Do we capture the explant information that was done at another facility? What can I use as Explant Reason? It is still not clear if a PFO is a congenital cardiac other or an ASD. Response No, the explant was done after the patient was discharged from your institution. ASD. What is the purpose of the CRT section? Currently upgrades to CRT are captured as other cardiac (e.g., lead/device upgrades). The intent is to capture biventricular synchronization. When a large number of cases are stratified as other due to maze, for example, what is the best way to analyze these results? This will need to be addressed at your individual sites. Take care not to include patients with atrial appendage amputation in this category. This will be addressed in the data specification upgrade. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 44 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 April-09 Oct-09 Section SeqNo M 2510 Field Name Other Card-Ao Aneur Data Specification disrupting the abnormal reentry pathways of electronic signals that lead to atrial fibrillation. Standard Surgical Maze Procedure: Surgical procedure in which full thickness incisions are made in the atrial of the heart. Surtures are then used to reapproximate the incised tissue. The resulting lesion disrupts the abnormal reentry pathways of electronic signals that lead to atrial fibrillation. Other Surgical Ablative Procedure: Surgical procedure in which lesions are created in the atria of the heart by an energy source. The lesion disrupts the abnormal reentry pathways of the electronic signals that lead to atrial fibrillation. Combination of Standard Surgical Maze Procedure and Other Surgical Ablative Procedure. Indicate whether the patient underwent an aortic aneurysm repair either in conjunction with, or as the primary surgical procedure. This includes dissections, non-dissections and ruptures of the aorta. Question Response Should a “transected aorta” be coded here? We have seen a few due to MVA and just want to make sure I am coding the procedure correctly. Yes, code as Ao Aneurysm. Where/how should non-aortic aneurysm/dissection data be documented? How should aortic transsection be documented? Should the procedure be documented in the aortic section or as an other cardiac procedure? Correct, the field clarification states: aneurysm may refer to the “pathologic or traumatic dissection, non-dissection and ruptures of the aorta. This may include traumatic disruption, transsection or dilated aorta. Yes, these cases should be captured in Seq.No.2510 for aortic aneurysm. Yes. When the patient has an aortic root replacement should we also code aortic aneurysm? NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 45 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date April-09 Section M SeqNo 2520 Field Name Other Card-Asc Oct-08 M 2540 Other Card-Desc Data Specification Indicate if the patient underwent repair of ascending aortic aneurysm either in conjunction with, or as the primary surgical procedure. Aneurysm refers to pathologic dilatation of the aorta. The ascending aorta begins at the aortic annulus and ends at the origin of the innominate artery where the aorta continues as the transverse arch. Indicate if the patient underwent repair of a descending aortic aneurysm either in conjunction with, or as the primary surgical procedure. The descending aorta is the portion of the aorta between the arch and the abdomen. Feb-10 Jun-08 M 2560 Other Card-Other Indicate whether the patient had an other cardiac procedure performed either in conjunction with, or as the primary surgical procedure that is not included within this section. Includes, but is not limited to those procedures listed on the STS Data Manager's section of the STS Web Site. Question The procedure ascending aorta plus AVR is captured as a valve procedure. Should the ascending aorta also be captured as an “other cardiac procedure” with the corresponding aorta questions answered? Response In addition to capturing the AVR in SeqNo 1630, the repair of the ascending aorta should be captured in SeqNo 2510 and 2520 to describe the disease in the aorta, and its location. Please clarify if TAG or EVAR thoracic aorta cases are to be added under Other Cardiac Procedures? No. Do not code as Other, capture in Other Card – Desc. CT Surgeon placed TEVAR in IR suite due to OR availability. IR suite is treated as OR and Op Report is generated. Can this case be counted? If the patient is taken to the OR for lead placement only should that be included in the database. Yes, include these thoracic endovascular repairs in the adult cardiac surgery database. No. Sep-08 If the patient has A/V disruption during a mitral valve replacement requiring repair, does that make the case Valve + Other Cardiac Other? No, this case should be coded as Valve only as that was the intended procedure. Oct-08 How would a pacemaker insertion by cardiologist during same hospitalization of CABG be coded? If the pacemaker is implanted in the post operative period by a cardiologist, code in Seq# 3010 Comps-Other-Other. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 46 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jan 09 Feb 09 July-09 Nov-09 Section SeqNo Field Name Data Specification Question The cardiac surgeon takes the patient to the OR for epicardial lead placement via thoracotomy as a primary procedure. Should this procedure be included in the adult cardiac database? The following cases can be coded as Other Cardiac Other. This list is not all-inclusive and will be updated as needed to identify appropriate cases to capture in this sequence number. The operative report states AVR and resection of anterior mediastinal mass. After the sternum was opened, mediastinal adenopathy was encountered and resected en bloc. Should this be coded as Valve + Other? A general surgeon placed a central venous catheter for apheresis. Post operatively the patient did not respond well. Interventional radiology took the patient to the x-ray and discovered that the dialysis catheter was inadvertently placed in the ascending aorta. The CT surgeon took the patient emergently to the OR and reopened a previous sternotomy, removed the catheter and repaired the aorta with perfusion standby. Should this be included in the adult cardiac database? Response Yes, this case should be captured as Other. Pulmonary valvectomy Pulmonary embolectomy Repair prosthetic valvular dehiscence Thorocotomy for placement of epicardial pacemaker leads Apical aortic conduit Myxoma Septal myectomy Myocor coapsys device Resection ruptured vein graft aneurysm Code AVR only. Yes, code this case as Other Cardiac Other. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 47 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Mar-10 Mar-10 Section SeqNo Field Name Data Specification Question The patient had a known large pseudoaneurysm extending cephalad toward the sternal notch. During cardiopulmonary bypass and attempts to expose the right atrium for cardioplegia cannulation in the left atrium for left ventricular vent catheter, the pseudoaneurysm was entered. There was a lot of difficulty in maintaining perfusion due to loss of blood through the pseudoaneurysm. Digital inspection revealed that there was more than one source of this pseudoaneurysm, and we were unable to obtain good proximal and distal control. There was no perfusion to the right coronary artery during attempts to maintain hemostasis. After a period of cooling and further exposure, it became clear that the situation was not fixable, in my judgment. We elected to discontinue the procedure and the patient was pronounced dead at 10:40 a.m. Appropriate contact was made with the medical examiner and full discussion was undertaken with family members. They understood that this was not an unexpected result. Intended procedure is CABG post acute MI. Skin incision of 4-5 inches in thoracic area of adipose tissue. At that point sternum still not located & procedure aborted. Since Sequence 2560 can be a primary surg procedure, seems to only choice. Sequence 2590 Other Non Cardiac Other Thoracic fits but is chosen only if done in conjunction with a primary surg procedure. While this may be a case for the adult thoracic database Response Code this case as “Other Cardiac Other.” Code this case as “Other Cardiac Other.” NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 48 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Field Name Data Specification Apr-10 June-10 Dec-09 N 2600 Other Non CardOther Indicate whether the patient had any other non-cardiac procedure performed in conjunction with the primary surgical procedure that is not included within this section. Dec-09 Mar-08 O 2650 Blood Prod Platelet Units Oct-09 O 2660 Extubated In OR Indicate the number of units of platelets that were transfused postoperatively. Count the dose pack as one unit. A dose pack may consist of 4,6,8,10 or any number of donor platelets obtained. The number of units coded is not volume dependent. Indicate whether the patient was extubated prior to leaving the operating room during the initial surgery. Question (we do not have), I am asking you to determine whether this case gets entered in the STS Adult Cardiac database or not. Patient was scheduled for aortic valve repair/replacement, was taken to OR, sternotomy performed and an epiaorta ultrasound done. Based on those results and the patients comorbid conditions valve procedure was abandoned, sternotomy and chest were closed. Patient was never placed on bypass. Should this case be coded and included in the Adult Cardiac Database? Should an aortoplasty patch on the root or ascending aorta done in conjunction with a valve replacement or CAB be coded as other? We have a patient that had an emergent CABG X3. Just prior ( same OR time) the patient had to have a Cystoscopy with Urethral Dilatation and insertion of Foley Cath. Would this be an other non cardiac surgery OR just a CABG as planned? A bone marrow biopsy of the sternum was performed on a CABG pte. in the OR. Should this be coded as Other Non-Card-Other or Isolated CABG? In sequence number 1500 states to code random donor platelets which consist of 4,6,8 or 10 units and single donor platelets as ONE dose. That is inconsistent with the definition of post operative platelet doses. Shouldn't we code them the same? When will the STS include data about the patients extubated in the OR in the harvest reports? Response Include the case and capture it as “Other Cardiac Other.” Yes, code other cardiac other. This is isolated CAB. This is isolated CAB. Yes, when platelets are administered, a dose pack is counted as "1 unit". This can be done with the next harvest report. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 49 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section P SeqNo 2720 Field Name Comps-Op-ReOp Bleed/Tamponade Data Specification Indicate whether the patient returned to the operating room for mediastinal bleeding/tamponade. Question Patient develops a postop pericardial effusion and returns to the OR 1 week post CABG for exploration and drainage of blood. He is never hemodynamically unstable/does not exhibit symptoms of acute tamponade. Is this a Re-Op Bleed/Tamponade or a Re-Op OtherCard or? The Patient had CABx2, LIMA in first surgery. shortly after he developed bleeding/tamponade and returned to OR. The surgeon who performed the initial surgery was in OR with a different patient so a different surgeon did the second surgery. In the second surgery a hybrid procedure was performed (saphenous vein to LIMA to heart) question #1: two CAB surgery, different surgeons, do I complete two DCF and enter this patient twice or is it simply a re-op bleed and the second CAB isn't entered? second question: if I am to enter a second DCF how should I enter the hybrid grafts? svg to LIMA to heart? Does an AICD done in the EP lab count as Re-Op Other Cardiac? Response This is coded Re-op Bleed/Tamponade. Mar-08 Does a Cardiac Cath done in the same hospitalization as a CAB get coded as Re-Op Other Cardiac? Do not code Re-Op Other Cardiac for Cardiac Cath done in the same hospitalization as a CAB. Jan-09 During a re-do CAB, the epicardial leads were cut and new leads were tunneled close to the previously placed pacemaker. The patient returns to the OR prior to discharge for connection to the pacemaker, how should the return to the OR be captured? If this procedure was planned, do not capture the return to the OR. Feb-10 Mar-08 P 2750 Comps-Op-ReOp Other Card Indicate whether the patient returned to the operating room for other cardiac reasons. The return to the operating room should be coded as reoperation for bleeding only. Do not code Re-Op Other Cardiac for AICD done in the EP lab. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 50 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Nov-09 Section SeqNo Oct-08 P 2760 Comps-Op-ReOP Other Non Card Feb 09 P 2770 Comps-OpPerioperative MI Oct-09 Dec-09 Field Name Data Specification Indicate whether the patient returned to the operating room for other noncardiac reasons. This includes procedures requiring a return to the operating room such tracheostomy, hematoma evacuation, delayed sternal closure. This does not include procedures performed outside the operating room such as GI Lab for peg tube, shunts for dialysis, etc. (0-24 hours post-op) Indicate the presence of a peri-operative MI(0-24 hours post-op) as documented by the following criteria: The CK-MB (or CK if MB not available) must be greater than or equal to 5 times the upper limit of normal, with or without new Q waves present in two or more contiguous ECG leads. No symptoms required. (>24 hours post-op) Indicate the presence of peri-operative MI (>24 hours post-op) as documented by at least one of the following criteria: 1. Evolutionary ST - segment elevations. 2. Development of new Q-waves in two or more contiguous ECG leads. 3.New or presumably new LBBB pattern on the ECG. 4. The CK-MB (or CK if MB not available) must be greater than or equal to 3 times the upper limit of normal. Because normal limits of certain blood test may vary, please check with your lab for normal limits for CK-MB and total CK. Question A patient went to the OR for removal of an LVAD and then the next day unfortunately had to have the LVAD reinserted. How should the reinsertion be coded? Patient had cath as cardiac work-up prior to hip replacement. Cath showed significant CAD. Patient went to OR for CABG, then during the same admission had a hip replacement. As this procedure was planned prior to CABG, it is not a complication. Should this be coded as a Re-Op or not? Response Code Reop Other Cardiac. Multiple questions have been raised about patients who meet the specifications for perioperative MI by enzyme changes or EKG changes, but have had specific procedures done that may have caused those changes. If the patient had a Coronary Endarterectomy and meets the criteria for MI by enzymes or EKG changes, then code “Yes” to Perioperative MI. This does not apply for patients that had a left ventricular resection or LVAD placement. Yes. We don’t routinely do CPKs or EKGs post op. We are involved in a study that requires that we draw them. We are seeing some periop MIs based on the values but the surgeons don’t think we have to code them in our STS outcomes. The concern is all sites don’t routinely draw CPKs. Do we have to code the perioperative MI if we have the value that meets criteria? Postop MVR + Cryo MAZE the surgeon documents that the CK-MB elevation seen was secondary to the MAZE. I see no changes in the postop EKG that would reflect an acute infarct, but the enzymes were greater than 10X uL/nl. Do I code this No. Do not code as a re-op. It was a planned procedure. This should be coded as complications peri-operative MI. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 51 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Feb-08 P 2780 Field Name Comps-InfectStern Deep Data Specification Indicate whether the patient, within 30 postoperatively, had a deep sternal infection involving muscle, bone, and/or mediastinum Requiring Operative Intervention. Must have ALL of the following conditions: 1. Wound opened with excision of tissue (I&D) or re-exploration of mediastinum. 2. Positive culture. 3. Treatment with antibiotics. Mar-08 Jun-08 Feb-08 Dec-09 P 2830 Comps-NeuroStroke Perm Indicate whether the patient has a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in cerebral blood supply) that did not resolve within 24 hours. Question as a postop complication/Perioperative MI? We draw postop MB's on all cases, so this is a recurring sticky wicket for me in coding. If deep sternal wound infection is captured in the Complications section of the data collection form should all readmissions for all infections be captured in the Complications section or in the Readmission section? The patient was discharged on POD #7 and readmitted with DSWI on POD #29 but doesn't have surgery until POD #40. Does this count as DSWI? The patient has endocarditis and has been treated with ABX, on POD#10 the patient goes to the OR for flaps and the cultures are negative. Is this DSWI? If the patient experiences confusion, delirium and/or encephalopathic events that resolve within 72 hours; is that considered Stroke Permanent? I have a patient that had a chorioretinal scar noted on eye exam after over 2 weeks of "spot" noted on vision of one eye. Have Physicians noting CVA and another noted TIA. H&P prior to surgery stated that patient had small embolic stoke from abnormal aortic valve, with NO evidence of CVD on MRI/MRA. How would you capture this? Response This circumstance is specific to DSW infection only. Do not include other infections in the complications when readmitted. Yes, it does. Code "Yes" to CompsInfect-Stern Deep. Yes, this is DSWI and should be coded as such. Neurological deficits such as confusion, delirium and/or anoxic or metabolic encephalopathy are not coded as stroke. There is not enough information to code complications stroke permanent. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 52 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Mar-10 Section P SeqNo 2850 Field Name Comps-NeuroCont Coma >=24 hrs. Oct-08 P 2851 Comps-NeuroParalysis Feb-08 P 2860 Comps-Pulm-Vent Prolonged Data Specification Indicate whether the patient had a new postoperative coma that persists for at least 24 hours secondary to anoxic/ischemic and/or metabolic encephalopathy, thromboembolic event or cerebral bleed. Indicate whether the patient had a new postoperative paralysis or paraplegia. Question How should the patient with metabolic or anoxic encephalopathy be captured in the post operative complications? Response Until the specifications can be changed with the next data specification upgrade, code metabolic and anoxic encephalopathy as continuous coma. The patient has a stroke with hemiplegia, is it captured here? Indicate whether the patient had prolonged pulmonary ventilator > 24 hours. Include (but not limited to) causes such as ARDS, pulmonary edema, and/or any patient requiring mechanical ventilation >24 hours postoperatively. The fields for initial hours ventilated and total hours ventilated are not in the new data specifications. How do we capture prolonged vent? This field is intended to capture paralysis that is not CNS related, but rather related to spinal cord problems or other. Paralysis related to stroke is captured in the stroke fields. Prolonged ventilation will require calculating the initial hours ventilated by subtracting the time in minutes from initial intubation to OR exit from the initial time of extubation. For example, the initial intubation at 08:00, exit OR 12:00, initial extubation 16:00. Initial intubation hours = 4 hours. Code "NO" to prolonged vent. Initial intubation time - OR exit time + ADDITIONAL hours ventilated. [ Seq.# 1337 - Seq.# 1336] + [ Seq.# 2690] The total of the two fields will then be used to complete prolonged ventilation. No, there is no mechanism to subtract reop time is version 2.61. Mar-08 Clarify how prolonged vent is calculated, please? Jun-08 In the past the time the patient is in the OR for reop was subtracted from the post op vent time, is that still deducted in 2.61? The patient was diagnosed with pneumonia preop and was treated with ABX, post operatively the CXR shows pneumonia that has worsened; should this be coded as a complication? Jun-08 P 2880 Comps-PulmPneumonia Jun-08 P 2890 Comps-RenalRenal Failure Indicate whether the patient had Pneumonia diagnosed by any of the following: positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia (which may include chest x-ray diagnostic of pulmonary infiltrates. Indicate whether the patient had acute or worsening renal failure If the patient is on peritoneal dialysis preop and hemo-dialysis post op, is Yes. This is preop renal failure as a risk factor but is not coded as a NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 53 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Field Name Oct-08 Data Specification resulting in one or more of the following: 1. Increase of serum creatinine to >2.0 and 2X most recent preoperative creatinine level. 2. A new requirement for dialysis postoperatively. Oct-08 Oct-08 Oct-09 Jul-08 Oct-08 P 2900 Comps-RenalDialysis Req Indicate whether the patient had a new requirement for dialysis postoperatively, which may include hemodialysis, peritoneal dialysis, and any form of ultrafiltration. Question this coded as post op renal failure? If a patient requires dialysis for hyperkalemia post-op and the pre-op creatinine was 1.3 and the post-op creatinine was only 1.6, how do we code this? Why aren’t GFR values used to determine renal failure vs. creatinine levels? If a patient has a history of hemodialysis, but is not receiving therapy at the time of surgery, but starts again postop, does this fall under renal failure? We use a compliance monitor that codes renal failure as an increase in creatinine of 0.2 for increased reimbursement. The surgeons don’t want to provide the documentation as they follow the STS definitions. What do you recommend? The Training Manual (TM) under Risk Factor Renal Failure Dialysis (seq. #450) states Code "No" for renal dialysis if ultra-filtration is the only documentation found, and for Complications-Renal-Dialysis the TM states under intent, that any form of ultra-filtration does count for dialysis. Can you clarify if a pt. has ultrafiltration pre-op and post-op, is this new dialysis? A July 08 FAQ is related to hemodialysis and peritoneal dialysis started post-op only to be counted if Creatinine >2.0, and twice the preop value? We have observed several patients presenting for heart surgery with severe pre-op renal dysfunction with Creatinine 4.0, knowing that dialysis would probably be needed Response complication. Renal Failure would not be coded. The patient’s dialysis was a result of hyperkalemia not renal failure, and the creatinine does not meet the criteria either. Because the GFR is a derived value. Yes, this would be a new requirement for dialysis postop (patient not receiving preop). Follow the STS definitions. To code ultrafiltration as dialysis postop, the patient's renal function must also meet the criteria with Creatinine >2.0 and 2X the baseline creatinine. Do not code ultrafiltration just for fluid removal. Code as Renal failure, New dialysis. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 54 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Apr-08 Section SeqNo P 2930 Field Name Comps-OtherHeart Block Data Specification Indicate whether the patient had a new heart block requiring the implantation of a permanent pacemaker of any type prior to discharge. Oct-08 Oct-08 P 2940 Comps-OtherCard Arrest Oct-08 P 2950 Comps-OtherAnticoag Event Indicate whether the patient had an acute cardiac arrest documented by one of the following: 1. Ventricular fibrillation 2. Rapid Ventricular tachycardia with hemodynamic instability. Indicate whether the patient had bleeding, hemorrhage, and/or embolic events related to anticoagulant therapy postoperatively. This may include patients who experience Disseminated Intravascular Coagulopathy (DIC) or Heparin Induced Thrombocytopenia (HIT). Oct-08 Feb 09 Oct-08 P 2960 Comps-OtherTamponade Indicate whether the patient had fluid in the pericardial space compromising cardiac filling, and requiring intervention other than returning to Question post-op as reflected in both surgeon and nephrology notes. In the past, those patients were counted as postop renal failure, dialysis required, even if the Creatinine did not go down to 8.0. What is your advice in this area? The patient has asystole and requires a permanent pacemaker. Does this qualify as heart block? Response Yes, code "Heart Block requiring permanent pacemaker." When pacemakers are inserted postop for Tachy-Brady syndrome, does this fall under Heart Block? A March 08 FAQ states that VT/Vfib requiring ICD would be coded as “Other,other”. Would this be coded twice, then, if a cardiac arrest occurred? Mark Seq# 2940 and 3010? Please clarify what types of things could fall in this category. Seems like quite a few pts have “thrombocytopenia” but not a lot of real HIT as documented by lab studies. What about blood clots/DVT? No. This is coded in Seq# 3010 Comps-Other-Other. Please clarify what would be coded as an “Anticoagulant ComplicationPharmacological”. Would this include Plavix? Multiple questions have been raised regarding patient who have positive assay for HIT but no clinical manifestations. Patient develops a late post-op pericardial effusion and has this evacuated in interventional radiology. The patient was not hemodynamically No. Do not include events related to Plavix as anticoagulant events. See other question and response and data definition for examples. Do not code anticoagulation event for patients with positive assay for HIT and no clinical manifestations of the complication. Yes, this required an intervention, and would be coded as a CompsOther-Tamponade. Yes. It is appropriate to code “Yes” to both. HIT is an anticoagulant event. Thrombocytopenia, blood clots or DVT are coded in Seq# 3010 CompsOther-Other. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 55 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo P 2970 Comps-Other-GI Event Oct-08 P 2990 Comps-Other-A Fib Mar-08 P 3010 Comps-OtherOther Oct-09 Oct-08 Field Name Data Specification the operating room, such as pericardialcentesis. This should be documented by either: 1. Echo showing pericardial fluid and signs of tamponade such as right heart compromise, or 2. Systemic hypotension due to pericardial fluid compromising cardiac function. Indicate whether the patient had a postoperative occurrence of any GI event, including but not limited to: 1. GI bleeding requiring transfusion 2. Pancreatitis with abnormal amylase/lipase requiring nasogastric (NG) suction therapy 3. Cholecystitis requiring cholecystectomy or drainage 4. mesenteric ischemia requiring exploration 5. Other GI event (e.g., Clostridium difficile). Indicate whether the patient had a new onset of atrial fibrillation/flutter (AF) requiring treatment. Does not include recurrence of AF which had been present preoperatively. Indicate whether a postoperative event occurred that is not identified in the categories above yet impacts hospital length of stay and/or outcome. Question unstable and the pericardiocentesis was scheduled rather than urgent/emergent. Is this still considered a tamponade? If not, what type of complication, if any, is this? Response Should shock liver be captured as a GI complication? Yes. If a patient has a history of afib, not currently treated other than Coumadin, is not in afib prior to OR, and develops afib post-op, is this counted as a complication? Does VT/Vfib requiring AICD count as Comps-Other-Other? No, the patient has a history of A-fib. Should we be coding post-op thoracentesis as “Other”? What about hemothorax and other similar conditions? The field says only if life threatening, however, if not treated, they could be! Code "Yes" for VT/Vfib in this field. Yes. These can be coded as CompsOther-Other. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 56 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Sept-09 Section SeqNo Field Name Data Specification Oct-09 Oct-09 Oct-09 Oct-09 Oct-09 Sep-08 Q 3050 Mort-Op Death Indicate whether the patient had an operative mortality. Includes both (1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days; and (2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure unless the cause of death is clearly unrelated to the operation. Question The patient was back from surgery @ 1950 and died the next day @ 0420. The cause listed on the death certificate was ARDS, Acute Lung Injury, and Protamine Reaction. He was not prolonged vent, should this be coded as Other – Other?, or just capture the mortality? We are being asked to code asymptomatic pleural effusions for increased reimbursement, please advise? Should comps other be coded for the patient who receives oral diabetic meds when not were taken preoperatively? If they are discharged on insulin? Should comps other be coded for the patient who is discharged on home O2? Should comps other be coded for the patient with thrombocytopenia that resolves prior to discharge? Should comps other be coded for the patient with post-pericardiotomy syndrome? If they are discharged on steroids? Response Capture the mortality and capture the complications as Other – Other. If the patient has a CAB 7/1 is discharged 7/10, readmitted 7/14 and has a redo CAB and dies before 30 days of the first surgery do we still enter the death in BOTH admissions. Won’t the surgeon be coded for the same patient’s death twice? Code the death in both data collection forms. All the data is need for completeness and accuracy. DCRI will implement analysis "rules" at the data warehouse level to exclude all operations that occur within 30 days of a previous operation, not just those cases that involved a double-counted mortality. Surgeons will not take a "double-mortality" hit. Many patients have pleural effusions that are asymptomatic and are not coded as a complication. No. NO NO. In a site specific field only if you are interested in this population. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 57 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section SeqNo Field Name Nov-09 Q 3070 Mort-Location Oct-08 Q 3080 Mort-Primary Cause Oct-08 Data Specification Indicate the patient's location at the time of death: Operating room (OR) during initial surgery Hospital (Other than Operating Room) Home Other Care Facility Operating Room (OR) during reoperation Unknown Indicate the PRIMARY cause of death, i.e. the first significant abnormal event which ultimately led to death; choose one of the following: Cardiac Neurologic Renal Vascular Infection Pulmonary Valvular Unknown Other Question Patient is discharged post CABG and returns 6 days later with massive CVA and dies. Is this considered operative mortality or is the cause of death “clearly unrelated” to the operation? (I think it is an operative mortality but others disagree.) The patient was transferred to another hospital for further acute care. While being transferred by helicopter, the patient died. How does location of death get coded? Response Yes. This is an Operative Mortality. When cause of death is listed as Multi-system Organ Failure, what should be marked? The first significant abnormal event that ultimately led to the patient’s death. This will likely be a judgment decision. Please clarify how to code when pt has become a DNR? It was in an email or something that it should be coded as “Other”. But when the actual cause is known, shouldn’t that be used? The actual cause of death should be coded. Examples of “clearly unrelated” would include being hit by a bus, or a meteor. The patient should be coded as though they died in your institution. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 58 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Jun-08 Section R SeqNo 3090 Oct-08 R 3130 Field Name ADP Inhibitors Discharge Data Specification Indicate whether or not the patient was discharged from facility on ADP Inhibitors, or if it was contraindicated or not indicated. The contraindication must be documented in the medical record by a physician, nurse practitioner, or physician assistant. Question What is the difference between not indicated and contraindicated? Ace or ARB Inhibitors Discharge Indicate whether or not the patient was discharged from facility on Ace or ARB Inhibitors, or if it was contraindicated or not indicated. The contraindication must be documented in the medical record by a physician, nurse practitioner, or physician assistant. Do both ACE and ARB inhibitors have to be addressed in order to be able to select “Contraindicated”? There are times when the d/c orders will read “lisinopril not ordered due to hypotension,” but then the ARB is not addressed. It is my understanding that ACE and ARB must be addressed for the Core measures, is this also true for STS? Postoperative patient develops renal failure. There is documentation that the ACE inhibitor is being held secondary to renal failure. The day of discharge the patient’s renal function is back to normal or very close to normal. The ACE inhibitor is not started at discharge and no further documentation as to why not. Is the answer “No” or “Contraindicated”? Are 23 hour OBVs considered readmissions? Oct-08 Mar-08 Oct-08 S 3220 Readmit <= 30 Days from DOP Indicate whether the patient was readmitted as an in-patient within 30 days from the date of initial surgery for ANY reason. This includes readmissions to acute care, primary care institutions only. Do not include readmissions to rehabilitations hospital, or nursing home. Please clarify how this is to be answered. The Training Manual refers to the transfer to an acute care Response "CMS' Coding for Quality: A Handbook for PQRI Participation, March 20, 2008" on page 4 defines: Not Indicated (absence of organ/limb, already received performed); Contraindicated (patient allergic history, potential adverse drug interaction). http://www.cms.hhs.gov/PQRI/Downl oads/2008PQRICodingforQualityHan dbook.pdf No, the STS definition includes “or”. Please code as “Contraindicated”. Code “No” as there is no documentation why it was not ordered on discharge. No, the patient has to be officially readmitted as an inpatient to be considered a Readmission. This is a Readmission. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 59 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Field Name Data Specification Oct-08 Oct-09 June-10 Oct-08 S 3230 Readmit Reason Indicate the primary reason that the patient was readmitted as an inpatient within 30 from the date of initial surgery (select one): Anticoagulation complication Valvular Anticoagulation complication Pharmacological Arrhythmia/Heart Bock Congestive Heart Failure Myocardial Infarction and/or Recurrent Angina Question facility as a Readmission. In the past, we have collected this simply in the Discharge Location (Seq#3190) as “Other Hospital”. Please clarify a discrepancy for Readmission within 30 days or less. The Training Manual includes observation patients that meet certain criteria. The v2.61 FAQ document answered a question submitted March 2008 stating “the patient has to be officially readmitted as an inpatient to be considered a readmission.” Why are patients that are transferred directly from my hospital to another counted as a readmission? Will the STS consider adding a data field to capture transfers rather than calling them readmissions? The patient was a planned hybrid and had an endoACAB at our Hospital and then transferred to another Hospital in our system for stent. The transfer was done for logistical reasons, should this be considered a readmission. The data definition states that 3 conditions must all be met to code this as a deep sternum infection (within 30 days postoperatively). One of the conditions is “Wound opened with excision of tissue (I&D) or reexploration of mediastinum.” The Training Manual states “may or may not require surgical intervention but antibiotic therapy instituted…” Which is correct? Response The FAQ document supersedes the Training Manual (which is a static document as are the data specifications.) An Observation patient is not coded as a Readmission. The original intent was to capture patients who were transferred for continued acute care, for example, the patient that requires a VAD or transplant. The data specification upgrade will need to address other transfer reasons. This is a readmission. All three conditions must be met. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 60 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Oct-08 Section SeqNo Field Name Oct-09 Mar-08 S 3240 Readmit Reason Primary Procedure Data Specification Pericardial Effusion and/or Tamponade Pneumonia or other Respiratory Complication Coronary Artery Dysfunction Valve Dysfunction Infection - Deep Sternum Infection - Conduit Harvest Site Renal Failure TIA Permanent CVA Acute Vascular Complications Subacute Endocarditis VAD complication Other - Related Readmission Other - Nonrelated Readmission Indicate the primary procedure that the patient received after being readmitted as an in-patient within 30 days from the date of initial surgery (select one): OR for Bleeding Pacemaker insertion/AICD PCI Pericardiotomy/Pericardiocentesis OR for Coronary Arteries OR for Valve OR for Sternal Debridement/Muscle Flap Dialysis OR for Vascular No Procedure Performed Other Procedure Unknown Question Please clarify what would be coded as an “Anticoagulant ComplicationPharmacological”. Would this include Plavix? The patient was readmitted with DVT, started on heparin and discharged on Coumadin. Should this be captured as an acute vascular complication or as other related complication? Response HIT is an example of anticoagulation complication. Plavix is not included. The patient was discharged on POD #7 and readmitted with DSWI on POD #29 but doesn't have surgery until POD #40. Do I need to code the readmission procedure? Yes, Code "OR for Sternal Debridement/Muscle Flap". Do not code acute vascular complication for DVT, code other related readmission. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 61 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date May-08 Nov-08 Section - SeqNo 3450 Field Name Custom Text Field 1 (Medicare FFS) Data Specification Indicate if the patient is a Medicare Fee-for-Service (FFS) patient. Question Should this field be completed for all Medicare patients? If a patient has either "Part B Only" or "Part A & B", the surgeon's office would be sending claims under Part B (not Part A.) I am not understanding why a patient with both Part A & B would not be included in Medicare FFS. If the patient has "Part B Only", or "Part A & B", the patient still has Part B and that is what the surgeon is billing under. Please clarify. Response This field was activated on April 16, 2008 for purposes of the PQRI Registry Test. It is to be completed on all Medicare patients for any surgeon who has consented to participate in the PQRI Registry Test. Although not required for all patients, it is recommended that data managers consider completing this field now to avoid potential retrospective data collection in the future. A patient's Medicare FFS information may be obtained from the surgeon's office billing department. Ask "Are the claims for physician fee schedule services for this patient billed to the Medicare Carrier or Part A/B Medicare Administrative Contractor?" In other words, "Does the patient have Medicare Part B?" If so, code as "Yes". A key point of contact for this information would be the surgeon's office manager. Methods to obtain from office manager might include, but are not limited to: notification of medicare FFS patient when patient enters the hospital, weekly report from office manager. Clarification received from CMS: “We look at Medicare Part B claims contained in the National Claims History (NCH) file when calculating PQRI reporting via claims and when comparing eligible instances that an eligible professional (EP) reports to the registry. It does not matter if the patient is also covered under Part A, we simply do not look at that data. We are interested in the services that the EP who is reporting to the registry provides (Part B) not the hospital NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 62 of 63 The Society of Thoracic Surgeons Frequently Asked Questions (FAQ): Adult Cardiac Surgery Data Specifications, v 2.61 January 2008-July 2010 Date Section SeqNo Field Name Data Specification Question Response facility services (Part A). Hospital measures are covered in other quality performance programs. PQRI is interested in the quality of care provided by the EP. For your registry, this would be the surgeon performing the CABG or other procedure. So we will look at the number of procedures each unique TIN/NPI submits on a Part B claim. The reason we look at unique TIN/NPI is that a particular surgeon (NPI) may provide services through more than one practice or group (TIN). Separate reporting and performance calculations are made for each unique TIN/NPI. Incentive payments for each TIN/NPI is made to the TIN. Currently, Medicare Advantage (Part C) plans are not considered in PQRI. So, for our purposes, we need data on those patients who are covered for the EP services (surgery) under Medicare Part B.” Jan-10 I am still unclear if I can mark Medical reason for the PQRI database if a LIMA wasn't used because they bypassed a RCA vs LAD. STS Bottom line: If a patient has Medicare Part A & B, please code "Yes" to Custom Text Field, "Medicare FFS", Seq# 3450 if the surgical procedure claims (physician services) were submitted under Medicare Part B. If the IMA was not used because the patient did not have LAD disease, the field should be coded NO. Not having LAD disease is not a contraindication for using the IMA as a graft. NOTE: The 2.61 FAQ document includes only those data specifications that have a question and associated responses. The FAQ document will be cumulative and updated monthly. Please check the v2.61 Training Manual for additional information prior to submitting a clinical question. Page 63 of 63