Specifications Manual Changes for AMI and HF

1

• Specifications Manual Changes for AMI and HF
• Discharges 4Q09 1Q10

This material was prepared by IQH under a
contract with the Centers for Medicare Medicaid
Services (CMS), an agency of the U.S. Department
of Health and Human Services. The contents
presented do not necessarily reflect CMS policy.
Publication No IQH1423
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AMI/HF

• Adult Smoking
• Comfort Measures
• Discharge Status
• Documentation
• LVSD
• Reason for No ACEI and No ARB at Discharge

• AMI Only
• Dates and Times
• Reason for Delay in Fibrinolytic Therapy PCI
• Reason for No Beta-Blocker at Discharge
• HF Only
• Discharge Instructions Address Medications
• LVS Assessment

3
Adult Smoking

• Clarification Added
• Looking for definitive documentation the
  patient currently smokes or smoked during the
  past year
• Non-definitive examples
• Smoked in last year ?
• Probable smoker
• Most likely quit 3 years ago

4
Comfort Measures Only

• Changed
• Previously Any inclusion term YES
• Now Disregard those which clearly describe the
  term negatively, e.g., No comfort measures
• Added Exclusion
• Comfort Care Arrest (CCA)
• DNR-CCA
• DNRCC-A
• DNRCC-Arrest
• DNRCCA

5
Comfort Measures Only

• Changed
• AMI Measures Exclusion
• Now applies to all measures EXCEPT
• 7 (7a) Fibrinolytic Therapy Received Within 30
  Minutes of Hospital Arrival
• 8 (8a) Primary PCI Received Within 90 Minutes
  of Hospital Arrival

6
Discharge Status

• Changed
• 01 Discharged to home or self care
• No longer includes Assisted Living or jail or law
  enforcement
• Includes independent living
• 04 Discharged to a facility that provides
  custodial or supportive care
• Previously Discharged to an ICF
• This now includes Assisted Living Facilities

7
Discharge Status

• New
• 21 Discharged to court/law enforcement
• Includes jail, prison, other detention facilities

8
Documentation - General

• Clarification/New
• All documentation must be legible, timed, dated,
  and authenticated
• Documents must be authenticated by
• Written signatures, initials, computer key, or
  other codes (identified)
• Rubber stamps are not acceptable on any document
  within the medical record
• Handwritten, electronic signatures or facsimiles
  of originals are acceptable

9
LVSD

• Clarification Added
• Reports Consider Conclusion synonymous with
• Interpretation
• Impression
• Final Diagnosis
• Inclusion List A (Moderate/Severe LVSD) AND
  Inclusion List B (LVSD Severity not specified)
• Any systolic failure can be counted as left
  ventricular as long as it is not specifically
  identified as right

Conclusion section of report takes priority over
other sections.
10
Reason for No ACEI and No ARB at Discharge

• Conditional Holds ONLY count when
• The order to hold lists certain parameters
• AND
• The medication was held due to those
  parameters specified

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Reason for No ACEI and No ARB at Discharge

• Examples
• Physician Orders Hold ACEI/ARB if cough
  continues NO
• Physician Orders Hold ACEI/ARB if BP lt 90
  systolic. Nurse documents, Captopril held, BP
  70/120. YES

12
Only AMI

• Dates and Times
• Reason for Delay in Fibrinolytic Therapy PCI
• Reason for No Beta-Blocker at Discharge

13
Dates and Times
Elements Arrival, Fibrinolytic Administration,
First PCI

• New
• When converting Midnight/2400 to 0000, use
  other documentation (supportive) to determine if
  date should be changed
• For example Midnight or 2400 10/24/2009
• Should this be converted to 0000 10/25/2009?

14
Reason for Delay in Fibrinolytic Therapy PCI

• New
• Automatic Inclusions Added in Addition to
  Cardiopulmonary Arrest
• Balloon Pump Insertion
• Intubation

Remember timing Fibrinolytic Therapy - w/in 30
min of arrival PCI - w/in 90 min of arrival If
neither are done timely, you need to look for a
reason.
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Reason for Delay in Fibrinolytic Therapy PCI

• Balloon Pump Insertion

• Intubation

• Aortic balloon pump
• Intra-aortic balloon (IAB)
• Intra-aortic balloon counterpulsation (IABC)
• Intra-aortic balloon pump (IABP)
• Intra-aortic counterpulsation (IAC)
• Intra-aortic counterpulsation balloon pump (IACBP)

• Edotracheal intubation (ETT)
• Mechanical ventilation
• Nasotracheal intubation (NTI)
• Orotracheal intubation

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Reason for No Beta-Blocker at Discharge

• Changed
• Bradycardia (HR lt 60) while not on a Beta-blocker
• No longer automatically counted
• Must be one of the clearly documented reasons by
  physician.
• HR running in 50s. Hold off on beta-blocker
  therapy.

17
Reason for No Beta-Blocker at Discharge

• Conditional Holds ONLY count when
• The order to hold lists certain parameters
• AND
• The medication was held due to those
  parameters specified

18
Only HF

• Discharge Instructions Address Medications
• LVS Assessment

19
Discharge Instructions Address Medications

• Changed/Clarification Added
• If there is ONLY documentation of a plan to start
  or restart a medication (i.e., no other mention
  of that medication being a discharge medication)
• The medication is not REQUIRED in the discharge
  instructions
• However, if it is listed in the discharge
  instructions, it will be acceptable (not counted
  off)

20
Discharge Instructions Address Medications

• Changed
• Disregard all references to laxatives, antacids,
  vitamins, minerals, and food supplements, and
  herbs (PRN or not) or medications noted by class
  only (antihypertensives) where specific names
  are not specified
• Except Potassium

21
Discharge Instructions Address Medications

• Changed
• Discharge medication information included in a
  discharge summary dated after discharge will be
  counted up to 30 days after discharge

22
Discharge Instructions Address Medications

• Changed/Clarification Added
• Contradictory documentation Listing a
  medication as a discharge medication AND an
  undefined hold for that same medication
• Discharge summary has aspirin listed as a
  discharge medication (i.e., aspirin 1 tab q day)
• Discharge orders state ,Hold aspirin No

23
LVF Assessment

• Simplified
• Moved assessment inclusions from Appendix H to
  the element definition
• LVSF assessments done anytime prior to hospital
  arrival are acceptable
• Infer a test was done if LVSF is documented

24
LVF Assessment

• Simplified
• To determine if a reason for not assessing is
  documented
• Look for explicit documentation
• ESRD. Will not measure EF.
• Echo was technically difficult. LVSF could not
  be measured.
• Limited life expectancy. Will not do further
  evaluation.

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LVF Assessment

• Simplified
• To determine if a reason for not assessing is
  documented
• Deferrals to another physician ONLY COUNT if the
  reason/problem underlying the deferral is noted.
• Consulting cardiologist to evaluate patient for
  echo NO

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LVF Assessment

• New
• Planned Assessment for After Discharge
• Only count if a definitive plan is documented
  (i.e., assessment considered is not sufficient)
• Will do echo as outpatient
• Conflicting Documentation
• If there is documentation of BOTH a reason for
  not assessing AND documentation that LVSF was
  assessed or planned for after discharge, select
  YES

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LVF Assessment

• Changed
• Suggested Data Sources were consolidated and made
  more reasonable
• Modified LVSF Assessment Inclusions
• Akinesis, Dyskinesis and Hypokinesis must be
  described as Left Ventricular
• Deleted Wall Motion Study from Other Tests

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Appendices

• Appendix A Coding Tables
• Appendix C Medication Tables
• Appendix H Miscellaneous Tables

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Appendix A Coding Tables

• Removed code 37.64
• Table 2.2 Left Ventricular Assistive Device
  (LVAD) and Heart Transplant

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Appendix C Medication Tables

• Several medications were removed from the US
  market and therefore deleted from
• Table 1.1 Aspirin/Aspirin-Containing Meds
• Table 1.4 Warfarin
• Table 1.6 Lipid-Lowering Med
• Medications Added
• Table 1.6 Lipid-Lowering Medications

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Appendix H Miscellaneous

• Retired Table 1.2 - LVSF Assessment Inclusion
  Table and incorporated it into the LVF Assessment
  element of the data dictionary
• Added Table 2.7 Allowable Measure Set
  Combinations

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Reminders - Contacts

• This presentation is a summary of changes
  related to discharges beginning with October 1,
  2009 through March 31, 2010. Please refer to the
  correct version of the Specifications Manual and
  Release Notes for all changes/editions.
• Contact Info
• Pam Henry 601-957-1575 x 202
• phenry_at_msqio.sdps.org
• IQH Web site www.IQH.org