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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