healthcare outcomes center

CaliforniaCaliforniaCABGCABGOutcomes Outcomes ReportingReportingProgram Program

HospitalHospitalAbstractor Abstractor TrainingTraining

May 16, 2008May 16, 2008

• IntroductionsIntroductions• CCORP updateCCORP update

– Data toolData tool– 2009 data collection2009 data collection– 2005-2006 Public Report2005-2006 Public Report

Introductions and UpdateIntroductions and Update

• Inform hospitals of changes made to CCORP effective Inform hospitals of changes made to CCORP effective with data beginning January 2008 dischargeswith data beginning January 2008 discharges

• Clarify data element definitions to improve coding of Clarify data element definitions to improve coding of CCORP risk factorsCCORP risk factors

• Only covering new and changed elements AND those Only covering new and changed elements AND those with coding issueswith coding issues

• See 2006 training (available on OSHPD website) for See 2006 training (available on OSHPD website) for elements not covered in this trainingelements not covered in this training

• Questions and AnswersQuestions and Answers

Purpose of TrainingPurpose of Training

Variables not covered in this trainingVariables not covered in this training

• Medical Record NumberMedical Record Number• Date of BirthDate of Birth• Patient AgePatient Age• SexSex• HeightHeight• WeightWeight

• Facility ID NumberFacility ID Number

• Date of SurgeryDate of Surgery• Date of DischargeDate of Discharge• Date of DeathDate of Death• Discharge StatusDischarge Status

• Responsible Surgeon Responsible Surgeon NameName

• Responsible Surgeon CA Responsible Surgeon CA License NumberLicense Number

Variables not covered in this trainingVariables not covered in this training

• DiabetesDiabetes• Chronic Lung DiseaseChronic Lung Disease• Cerebrovascular Accident Cerebrovascular Accident

timingtiming• DialysisDialysis• Previous CABGPrevious CABG• Prior PCI and intervalPrior PCI and interval• Myocardial Infarction – Myocardial Infarction –

TimingTiming• Left Main DiseaseLeft Main Disease• IncidenceIncidence

• CPB UtilizationCPB Utilization• CardioplegiaCardioplegia• Internal Mammary Internal Mammary

Artery(ies) Used as GraftsArtery(ies) Used as Grafts• Radial Artery UsedRadial Artery Used

New coding strategyNew coding strategy

• Harvest codingHarvest coding• Most elements will now be numericMost elements will now be numeric

• Director of the Regional Heart Failure Program for Director of the Regional Heart Failure Program for Kaiser Permanente Northern CaliforniaKaiser Permanente Northern California

• • • Graduated from UCSF School of Medicine and trained Graduated from UCSF School of Medicine and trained in Internal Medicine, Cardiology, and Heart Failure at in Internal Medicine, Cardiology, and Heart Failure at UCLAUCLA

• • • Was a UCLA Robert Wood Johnson Clinical ScholarWas a UCLA Robert Wood Johnson Clinical Scholar• • • Recognized as one of the “Outstanding Physicians of Recognized as one of the “Outstanding Physicians of

the Year" at UCLAthe Year" at UCLA• • • Has been involved in training and consulting for both Has been involved in training and consulting for both

the voluntary and mandatory CABG programs since the voluntary and mandatory CABG programs since 19951995

Dr. Anthony SteimleDr. Anthony Steimle

Review of Isolated CABG DefinitionReview of Isolated CABG Definition

• All Maze procedures are considered All Maze procedures are considered isolated, isolated, effective with January 2008 discharges.effective with January 2008 discharges.

Race and Ethnicity (New)Race and Ethnicity (New)

• Race – WhiteRace – White• Race – Black/African AmericanRace – Black/African American• Race – AsianRace – Asian• Race – American Indian /Alaskan NativeRace – American Indian /Alaskan Native• Race – Native Hawaiian/ Pacific IslanderRace – Native Hawaiian/ Pacific Islander• Race – OtherRace – Other

– Note: May code yes to more than oneNote: May code yes to more than one

• Hispanic or Latino EthnicityHispanic or Latino Ethnicity

Hispanic or Latino EthnicityHispanic or Latino Ethnicity

Indicate if the patient is of Hispanic or Latino Indicate if the patient is of Hispanic or Latino ethnicity as determined by the patient/family. ethnicity as determined by the patient/family. Hispanic or Latino ethnicity includes patient Hispanic or Latino ethnicity includes patient report of Cuban, Mexican, Puerto Rican, South or report of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or Central American, or other Spanish culture or origin, regardless of race.origin, regardless of race.

Valid Values: Yes; NoValid Values: Yes; No

Hypertension (Revised)Hypertension (Revised)

The patient has a diagnosis of hypertension, The patient has a diagnosis of hypertension, documented by documented by oneone of the following: of the following:

1.1. Documented history of hypertension diagnosed and Documented history of hypertension diagnosed and treated with medication, diet and/or exercisetreated with medication, diet and/or exercise

2.2. Prior documentation of blood pressure >140 Prior documentation of blood pressure >140 mmHg systolic or 90 mmHg diastolic for patients mmHg systolic or 90 mmHg diastolic for patients without diabetes or chronic kidney disease,without diabetes or chronic kidney disease, OR OR prior documentation of blood pressure >130 mmHg prior documentation of blood pressure >130 mmHg systolic or 80 mmHg diastolic on at least 2 occasions systolic or 80 mmHg diastolic on at least 2 occasions for patients with diabetes or chronic kidney for patients with diabetes or chronic kidney diseasedisease

3.3. Currently on pharmacologic therapy to control Currently on pharmacologic therapy to control hypertension hypertension

Hypertension – ClarificationHypertension – Clarification

CCORP requires CCORP requires • Chart documentation of a history of hypertensionChart documentation of a history of hypertension• Do not make diagnosis based on BPs or Do not make diagnosis based on BPs or

medications if the diagnosis was not made by medications if the diagnosis was not made by clinicians caring for the patient.clinicians caring for the patient.

STS Training Manual Clarification STS Training Manual Clarification • Diagnosis of HTN should not be based on a single Diagnosis of HTN should not be based on a single

readingreading• Code “Yes” if patient has normal BP but is on Code “Yes” if patient has normal BP but is on

antihypertensive medicationantihypertensive medication

Infectious EndocarditisInfectious Endocarditis (New) (New)

Indicate whether the patient has a history of Indicate whether the patient has a history of infectious endocarditis documented by infectious endocarditis documented by oneone of the of the following: following:

• positive blood cultures, positive blood cultures, • vegetation on echocardiography and/or other vegetation on echocardiography and/or other

diagnostic modality, or diagnostic modality, or • documented history of infectious endocarditisdocumented history of infectious endocarditisNOTE: Positive blood culture alone is not NOTE: Positive blood culture alone is not

sufficient to code “”Yes”. CCORP requires chart sufficient to code “”Yes”. CCORP requires chart documentation.documentation.

Infectious Endocarditis – ClarificationInfectious Endocarditis – Clarification

1.1. Code “Yes” if a patient with a past history of Code “Yes” if a patient with a past history of infectious endocarditis, treated and received infectious endocarditis, treated and received valve replacement surgery.valve replacement surgery.

2.2. For this to be coded ‘Yes” a diagnosis of For this to be coded ‘Yes” a diagnosis of infectious endocarditis must be a known risk infectious endocarditis must be a known risk factor preopfactor preop

3.3. If discovered intra-op, code “No”If discovered intra-op, code “No”

Peripheral Arterial Disease (Revised)Peripheral Arterial Disease (Revised)

Indicate whether the patient has a history of peripheral Indicate whether the patient has a history of peripheral arterialarterial disease (disease (includes upper and lower extremity, renal, includes upper and lower extremity, renal, mesenteric, and abdominal aortic systems).mesenteric, and abdominal aortic systems). This can This can include: 1) claudication, either with exertion or at rest, 2) include: 1) claudication, either with exertion or at rest, 2) amputation for arterial amputation for arterial vascularvascular insufficiency, 3) insufficiency, 3) vascular vascular reconstruction, bypass surgery, or percutaneous reconstruction, bypass surgery, or percutaneous intervention to the extremities (excluding dialysis fistulasintervention to the extremities (excluding dialysis fistulas and vein stripping), 4) documented aortic aneurysm with or and vein stripping), 4) documented aortic aneurysm with or without repair, 5) positive noninvasive test (e.g., ankle brachial without repair, 5) positive noninvasive test (e.g., ankle brachial index =<0.9, ultrasound, magnetic resonance or computed index =<0.9, ultrasound, magnetic resonance or computed tomography imaging of >50% diameter stenosis in any tomography imaging of >50% diameter stenosis in any peripheral artery, i.e. renal, subclavian, femoral, iliac). peripheral artery, i.e. renal, subclavian, femoral, iliac). Peripheral arterial disease excludes disease in the carotid or Peripheral arterial disease excludes disease in the carotid or cerebrovascular arteries.cerebrovascular arteries.

Cerebrovascular Disease (Revised)Cerebrovascular Disease (Revised)

Indicate whether the patient has CVD, Indicate whether the patient has CVD, documented by any one of the following: CVA documented by any one of the following: CVA (symptoms (symptoms >24 hours>24 hours after onset, presumed to after onset, presumed to be from vascular etiology); TIA (recovery within be from vascular etiology); TIA (recovery within 24 hours); non-invasive carotid test with 24 hours); non-invasive carotid test with >79%>79% diameter occlusion; or prior carotid surgery. diameter occlusion; or prior carotid surgery. Does not include neurological disease processes Does not include neurological disease processes such as metabolic and/or anoxic ischemic such as metabolic and/or anoxic ischemic encephalopathy.encephalopathy.

Cerebrovascular Disease - ClarificationCerebrovascular Disease - Clarification

• Cerebrovascular disease that is of ischemic, Cerebrovascular disease that is of ischemic, hemorrhagic, occlusive, aneurismal or rupture type origin hemorrhagic, occlusive, aneurismal or rupture type origin of the arterial system in the region of the head or neck. of the arterial system in the region of the head or neck. These are processes that have created some These are processes that have created some physiological abnormality in the arterial vessels. DO NOT physiological abnormality in the arterial vessels. DO NOT include any of the peripheral arterial disease processes.include any of the peripheral arterial disease processes.

• Code “Yes” for CVD if there is a history of a carotid artery Code “Yes” for CVD if there is a history of a carotid artery stent procedure.stent procedure.

CVD Type –Unresponsive Coma (New)CVD Type –Unresponsive Coma (New)

Indicate whether the patient has a history of Indicate whether the patient has a history of Unresponsive Coma greater than 24 hours: Unresponsive Coma greater than 24 hours: patient experienced complete mental patient experienced complete mental unresponsiveness and no evidence of unresponsiveness and no evidence of psychological or physiologically appropriate psychological or physiologically appropriate responses to stimulation.responses to stimulation.

CVD Type – TIA (New)CVD Type – TIA (New)

Indicate whether the patient has a history of a Indicate whether the patient has a history of a Transient Ischemic Attack (TIA): patient has a Transient Ischemic Attack (TIA): patient has a history of loss of neurological function that was history of loss of neurological function that was abrupt in onset but with complete return of abrupt in onset but with complete return of function within 24 hours.function within 24 hours.

CVD Type – Non Invasive >79% (New)CVD Type – Non Invasive >79% (New)

Indicate whether the patient has a history of Indicate whether the patient has a history of Non-invasive/invasive carotid test with greater than 79% Non-invasive/invasive carotid test with greater than 79% occlusion. occlusion.

STS Training Manual clarifies that: STS Training Manual clarifies that: • this element should be “Non Invasive >79%” and the test this element should be “Non Invasive >79%” and the test

measure >79% as well. measure >79% as well. • This test is also known as a carotid Doppler study. An This test is also known as a carotid Doppler study. An

angiogram of the carotid arteries can also be performed angiogram of the carotid arteries can also be performed by magnetic resonance angiography (MRA).by magnetic resonance angiography (MRA).

CVD Type – Prior Carotid Surgery CVD Type – Prior Carotid Surgery (New)(New)

Indicate whether the patient has a history of Indicate whether the patient has a history of previous carotid artery surgery and/or stenting. previous carotid artery surgery and/or stenting.

Cerebrovascular Accident (Revised)Cerebrovascular Accident (Revised)

Indicate whether the patient has a history of stroke (i.e. Indicate whether the patient has a history of stroke (i.e. any confirmed neurological deficit of abrupt onset any confirmed neurological deficit of abrupt onset caused by a disturbance in cerebral blood supply) caused by a disturbance in cerebral blood supply) that did not resolve within 24 hours. that did not resolve within 24 hours.

• Chart documentation of a diagnosis of CVA or stroke at Chart documentation of a diagnosis of CVA or stroke at any time prior to surgery is sufficient.any time prior to surgery is sufficient.

• STS Clarification: STS Clarification: The physical deficit can be in the The physical deficit can be in the form of extremity weakness, facial asymmetry, language form of extremity weakness, facial asymmetry, language (speech and/or cognitive thinking) impairment.(speech and/or cognitive thinking) impairment.

Immunosuppressive Treatment Immunosuppressive Treatment (Revised)(Revised)

Indicate whether the patient has used any form of Indicate whether the patient has used any form of immunosuppressive therapy within 30 days immunosuppressive therapy within 30 days preceding the operative procedure. preceding the operative procedure. This This includes, but is not limited to inhaled or includes, but is not limited to inhaled or systemic steroid therapy and chemotherapy. systemic steroid therapy and chemotherapy. This does not include This does not include topical applications, one topical applications, one time systemic therapy, time systemic therapy, or preoperative or preoperative protocol.protocol.

Immunosuppressive Treatment - Immunosuppressive Treatment - ClarificationClarification

• Steroids or other immunosuppressives given as part of surgical Steroids or other immunosuppressives given as part of surgical protocol, solely because the patient is undergoing CABG, do not protocol, solely because the patient is undergoing CABG, do not count.count.

Patients post organ transplant or with rheumatologic conditions Patients post organ transplant or with rheumatologic conditions may be on immunosuppressive therapy other than corticosteroids may be on immunosuppressive therapy other than corticosteroids such as:such as:

azathioprine (Imuran) cyclophosamide (Cytoxan)Methotrexatecyclosporine (Gengraf, Neoral, Sandimmune)tacrolimus (Prograf) sirolimus (Rapamune).mycophenolate mofetil - MMF (Cellcept)

Immunosuppressive Treatment - Immunosuppressive Treatment - ClarificationClarification

ClarificationClarificationDo notDo not include topical creams or inhalers (asthma) that include topical creams or inhalers (asthma) that

are steroidal in form. Do not include patients who are steroidal in form. Do not include patients who receive a one or two time dose of systemic treatment, receive a one or two time dose of systemic treatment, or a pre-operative/pre-cath protocol.or a pre-operative/pre-cath protocol.

There are four classes of drugs considered to be There are four classes of drugs considered to be immunosuppressive. Corticosteroids (only if taken immunosuppressive. Corticosteroids (only if taken systemically) Cytotoxic drugs, Antimetabolites and systemically) Cytotoxic drugs, Antimetabolites and Cyclosporine. Cyclosporine. Rheumatoid Arthritis drugs within 30 Rheumatoid Arthritis drugs within 30 days of surgery (ex: Enbrel, Humira or Remicade days of surgery (ex: Enbrel, Humira or Remicade infusions) code “Yes”infusions) code “Yes”

Last Creatinine Level Preop (Revised)Last Creatinine Level Preop (Revised)

Indicate the creatinine level Indicate the creatinine level closest to the date closest to the date and time prior to surgeryand time prior to surgery. A creatinine level . A creatinine level should be collected on all patients for should be collected on all patients for consistency, even if they have no prior history. A consistency, even if they have no prior history. A creatinine value is a high predictor of a patient's creatinine value is a high predictor of a patient's outcome and is used in the predicted risk outcome and is used in the predicted risk models. models.

Previous Valve (New)Previous Valve (New)

Indicate whether the patient had a previous Indicate whether the patient had a previous surgical replacement and/or surgical repair surgical replacement and/or surgical repair of a cardiac valve. This may also include of a cardiac valve. This may also include percutaneous valve procedures. percutaneous valve procedures.

STS Clarification:STS Clarification: This may include This may include percutaneous valve procedures such as percutaneous valve procedures such as percutaneous valvotomy or valvuloplasty, percutaneous valvotomy or valvuloplasty, as well as surgical valve repair or as well as surgical valve repair or replacement. replacement. Mitral clipping counts (i.e. Mitral clipping counts (i.e. code “Yes”)code “Yes”)

Previous Myocardial Infarction (New)Previous Myocardial Infarction (New)

Indicate if the patient has had at least one Indicate if the patient has had at least one documented previous myocardial infarction at documented previous myocardial infarction at any time prior to this surgery. An acute any time prior to this surgery. An acute myocardial infarction is evidenced by any of the myocardial infarction is evidenced by any of the following:following:


1. A rise and fall of cardiac biomarkers (preferably troponin) 1. A rise and fall of cardiac biomarkers (preferably troponin) with at least one of the values in the abnormal range for with at least one of the values in the abnormal range for that laboratory [typically above the 99th percentile of the that laboratory [typically above the 99th percentile of the upper reference limit (URL) for normal subjects together upper reference limit (URL) for normal subjects together with at least one of the following manifestations of with at least one of the following manifestations of myocardial ischemia: myocardial ischemia:


a. a. Ischemic symptoms;Ischemic symptoms;

b. b. ECG changes indicative of new ischemia (new ST-T changes, new ECG changes indicative of new ischemia (new ST-T changes, new left left bundle branch block, or loss of R wave voltage),bundle branch block, or loss of R wave voltage),

c. c. Development of pathological Q waves in 2 or more contiguous leads Development of pathological Q waves in 2 or more contiguous leads in in the ECG (or equivalent findings for true posterior MI);the ECG (or equivalent findings for true posterior MI);

d. d. Imaging evidence of new loss of viable myocardium or new regional Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality;wall motion abnormality;

e. e. Documentation in the medical record of the diagnosis of acute Documentation in the medical record of the diagnosis of acute myocardial infarction based on the cardiac biomarker pattern in the myocardial infarction based on the cardiac biomarker pattern in the absence of any items enumerated in a-d due to conditions that may absence of any items enumerated in a-d due to conditions that may mask their appearance (e.g., peri-operative infarct when the patient mask their appearance (e.g., peri-operative infarct when the patient cannot report ischemic symptoms; baseline left bundle branch block or cannot report ischemic symptoms; baseline left bundle branch block or ventricular pacing)ventricular pacing)


2. Development of new pathological Q waves in 2 or more 2. Development of new pathological Q waves in 2 or more contiguous leads in the ECG, with or without symptoms.contiguous leads in the ECG, with or without symptoms.

3. Imaging evidence of a region with new loss of viable 3. Imaging evidence of a region with new loss of viable myocardium at rest in the absence of a non-ischemic cause. myocardium at rest in the absence of a non-ischemic cause. This can be manifest as:This can be manifest as:

a. a. Echocardiographic, CT, MR, ventriculographic or nuclear imaging Echocardiographic, CT, MR, ventriculographic or nuclear imaging evidence of left ventricular thinning or scarring and failure to contract evidence of left ventricular thinning or scarring and failure to contract

appropriately (i.e., hypokinesis, akinesis, or dyskinesis)appropriately (i.e., hypokinesis, akinesis, or dyskinesis)

b. b. Fixed (non-reversible) perfusion defects on nuclear radioisotope Fixed (non-reversible) perfusion defects on nuclear radioisotope imaging (e.g., MIBI, thallium)imaging (e.g., MIBI, thallium)

4. Medical records documentation of prior myocardial infarction.4. Medical records documentation of prior myocardial infarction.

Previous Myocardial Infarction - Previous Myocardial Infarction - ClarificationClarification

Myocardial infarctions (MI) any time prior to surgery are counted. Chart reviewers Myocardial infarctions (MI) any time prior to surgery are counted. Chart reviewers should not attempt to diagnose an MI which was not diagnosed by the clinicians should not attempt to diagnose an MI which was not diagnosed by the clinicians caring for the patient (eg: Based on coder’s retrospective reading of ECG)caring for the patient (eg: Based on coder’s retrospective reading of ECG)

STS Clarifications: There is no time limit on when the myocardial infarction (MI) STS Clarifications: There is no time limit on when the myocardial infarction (MI) occurred. If the history and physical indicates there was a history of MI, yet no occurred. If the history and physical indicates there was a history of MI, yet no additional documentation is available to determine if definitional criteria are met, additional documentation is available to determine if definitional criteria are met, code as MI based on information provided. For an MI that has occurred during code as MI based on information provided. For an MI that has occurred during the same hospitalization as the surgery, definition criteria must be met. the same hospitalization as the surgery, definition criteria must be met.

Note: The current data specifications do not recognize echo as a method of Note: The current data specifications do not recognize echo as a method of documenting MI. Do not code MI based on echo reports: look for further documenting MI. Do not code MI based on echo reports: look for further supportive documentation.supportive documentation.

Heart Failure (Revised)Heart Failure (Revised)

Indicate whether, within 2 weeks prior to the initial surgical Indicate whether, within 2 weeks prior to the initial surgical procedure, a physician has diagnosed that the patient is currently procedure, a physician has diagnosed that the patient is currently in heart failure (HF). HF can be diagnosed based on careful in heart failure (HF). HF can be diagnosed based on careful history and physical exam, or by one of the following criteria:history and physical exam, or by one of the following criteria:

1.1. Paroxysmal nocturnal dyspnea (PND);Paroxysmal nocturnal dyspnea (PND);

2. 2. Dyspnea on exertion (DOE) due to heart failure;Dyspnea on exertion (DOE) due to heart failure;

3. 3. Chest X-ray (CXR) showing pulmonary congestion;Chest X-ray (CXR) showing pulmonary congestion;

4. 4. Pedal edema or dyspnea, and receiving diuretics; orPedal edema or dyspnea, and receiving diuretics; or

5. 5. Pulmonary edemaPulmonary edema..

Note: Severity is measured by NYHA Class within last two weeks. Note: Severity is measured by NYHA Class within last two weeks. Do not code stable, prior history.Do not code stable, prior history.

Heart Failure - ClarificationHeart Failure - Clarification

HF signs or symptoms must have occurred within 2 weeks prior HF signs or symptoms must have occurred within 2 weeks prior to surgery to code a patient as HF=Yes. Since evidence of to surgery to code a patient as HF=Yes. Since evidence of recent HF symptoms is not always available in current medical recent HF symptoms is not always available in current medical record, record, CCORP accepts chart documentationCCORP accepts chart documentation that the patient that the patient was diagnosed with a HF episode within the two weeks prior to was diagnosed with a HF episode within the two weeks prior to surgery.surgery.

STS Clarifications: The intent is to capture current diagnosis of STS Clarifications: The intent is to capture current diagnosis of or exacerbation of an existing condition. DO NOT code stable or exacerbation of an existing condition. DO NOT code stable or non-symptomatic compensated failure. A low ejection or non-symptomatic compensated failure. A low ejection fraction (EF) without clinical presentation does not qualify for fraction (EF) without clinical presentation does not qualify for history of heart failure.history of heart failure.

NYHA Classification (Revised)NYHA Classification (Revised)

Indicate the patient's Indicate the patient's highesthighest New York Heart Association (NYHA) New York Heart Association (NYHA) classification classification within 2 weekswithin 2 weeks prior to surgery. NYHA classification prior to surgery. NYHA classification represents the overall functional status of the patient in relationship to represents the overall functional status of the patient in relationship to heart failure. heart failure. NOTE: this is rarely specified in clinician notes. Read NOTE: this is rarely specified in clinician notes. Read chart and make best guess!chart and make best guess!

• Class I: Patient has cardiac disease but without resulting limitations of Class I: Patient has cardiac disease but without resulting limitations of ordinaryordinary physical activity. Ordinary physical activity (e.g., walking several blocks or climbing physical activity. Ordinary physical activity (e.g., walking several blocks or climbing stairs) does not cause undue fatigue, palpitation, dyspnea, or anginal pain. stairs) does not cause undue fatigue, palpitation, dyspnea, or anginal pain. Limiting Limiting symptoms may occur with marked exertionsymptoms may occur with marked exertion..

• Class II: Patient has cardiac disease resulting in slight limitation of ordinary physical 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 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 more than two blocks or climbing more than one flight of stairs results in limiting symptoms (e.g., fatigue, palpitation, dyspnea, or anginal pain).symptoms (e.g., fatigue, palpitation, dyspnea, or anginal pain).

NYHA ClassificationNYHA Classification

• Class III: Patient has cardiac disease resulting in marked Class III: Patient has cardiac disease resulting in marked limitation of physical activity. Patient is comfortable at rest. Less limitation of physical activity. Patient is comfortable at rest. Less than ordinary physical activity (e.g., walking one to two level than ordinary physical activity (e.g., walking one to two level blocks or climbing one flight of stairs) causes fatigue, palpitation, blocks or climbing one flight of stairs) causes fatigue, palpitation, dyspnea, or anginal pain.dyspnea, or anginal pain.

• Class IV: Patient has dyspnea at rest that increases with any Class IV: Patient has dyspnea at rest that increases with any physical activity. Patient has cardiac disease resulting in inability physical activity. Patient has cardiac disease resulting in inability to perform any physical activity without discomfort. Symptoms to perform any physical activity without discomfort. Symptoms may be present even at rest. If any physical activity is may be present even at rest. If any physical activity is undertaken, discomfort is increased.undertaken, discomfort is increased.

NYHA Classification - ClarificationNYHA Classification - Clarification

STS ClarificationSTS Clarification: Select the highest level of heart : Select the highest level of heart function leading up to episode of hospitalization or the function leading up to episode of hospitalization or the time of the procedure.time of the procedure.

STS Cardiogenic Shock (Revised)STS Cardiogenic Shock (Revised)

Indicate whether the patient was, at the time of Indicate whether the patient was, at the time of procedure, in a clinical state of hypo perfusion procedure, in a clinical state of hypo perfusion sustained for greater than 30 minutessustained for greater than 30 minutes, according , according to either of the following criteria: to either of the following criteria:

1.1. Systolic blood pressure (BP) < 80 and/or Systolic blood pressure (BP) < 80 and/or Cardiac Index (CI) < 1.8 despite maximal treatment.Cardiac Index (CI) < 1.8 despite maximal treatment.

2.2. Intravenous inotropes and/or intra-aortic Intravenous inotropes and/or intra-aortic balloon pump (IABP) necessary to maintain Systolic balloon pump (IABP) necessary to maintain Systolic BP > 80 and/or CI > 1.8. BP > 80 and/or CI > 1.8. NOTE: meds must NOTE: meds must continue into surgery otherwise code “No”continue into surgery otherwise code “No”

Resuscitation – Coding IssueResuscitation – Coding Issue

Whether the patient required cardiopulmonary Whether the patient required cardiopulmonary resuscitation within one hour before the start of the resuscitation within one hour before the start of the operative procedure.operative procedure.

STS Clarification: CPR must have been either started, STS Clarification: CPR must have been either started, on going or concluded within one hour before the start on going or concluded within one hour before the start of the operative procedure.of the operative procedure.

Coding issue = CCORP has received a number of Coding issue = CCORP has received a number of cases where patient was coded as “salvage” with cases where patient was coded as “salvage” with resuscitation = NOresuscitation = NO

Arrhythmia (Revised)Arrhythmia (Revised)

Indicate whether there is a history of preoperative Indicate whether there is a history of preoperative arrhythmia (sustained ventricular tachycardia, ventricular arrhythmia (sustained ventricular tachycardia, ventricular fibrillation, atrial fibrillation, atrial flutter, third degree heart fibrillation, atrial fibrillation, atrial flutter, third degree heart block) that has been treated with any of the following block) that has been treated with any of the following treatment modalities prior to the CABG surgery:treatment modalities prior to the CABG surgery:

1) 1) Ablation therapyAblation therapy

2)2) AICDAICD

3)3) PacemakerPacemaker

4)4) Pharmacological treatmentPharmacological treatment

5)5) ElectrocardioversionElectrocardioversion

Arrhythmia - ClarificationsArrhythmia - Clarifications

STS Clarifications: There is no time line to the presentation of STS Clarifications: There is no time line to the presentation of these arrhythmias. The arrhythmia must have been treated these arrhythmias. The arrhythmia must have been treated and/or clinically documented with one or more of the and/or clinically documented with one or more of the definitional list of therapies. These do not include arrhythmias definitional list of therapies. These do not include arrhythmias such as 1st or 2nd degree heart block, occasional premature such as 1st or 2nd degree heart block, occasional premature ventricular contractions (PVC’s) or supraventricular ventricular contractions (PVC’s) or supraventricular tachycardia (SVT). tachycardia (SVT).

If the patient had a history of an arrhythmia (i.e. a-fib or If the patient had a history of an arrhythmia (i.e. a-fib or

V-tach) and is currently on medication to control rate and V-tach) and is currently on medication to control rate and rhythm, and presents in sinus rhythm, code the patient “Yes”, rhythm, and presents in sinus rhythm, code the patient “Yes”, as having the arrhythmia. as having the arrhythmia.


To define “treated for an arrhythmia”: a patient is considered To define “treated for an arrhythmia”: a patient is considered to be treated for arrhythmia if they are on a medication to be treated for arrhythmia if they are on a medication specifically to treat an arrhythmia. Coumadin would not be specifically to treat an arrhythmia. Coumadin would not be considered a treatment for A-fib. considered a treatment for A-fib.

BOTTOM LINE: Code Arrhythmia ‘Yes” for any prior BOTTOM LINE: Code Arrhythmia ‘Yes” for any prior arrhythmia historyarrhythmia history


Rather, patients may be on Coumadin to treat potential Rather, patients may be on Coumadin to treat potential complications of the arrhythmia but not to treat the complications of the arrhythmia but not to treat the arrhythmia. Patients may or may not be on Digoxin to treat arrhythmia. Patients may or may not be on Digoxin to treat arrhythmias. In the past Digoxin was used to treat A-fib, but arrhythmias. In the past Digoxin was used to treat A-fib, but patients can also be on Digoxin to decrease the O2 patients can also be on Digoxin to decrease the O2 demands on the heart, increase contractility etc.demands on the heart, increase contractility etc.

Therefore, do not assume that all patients that are on Digoxin Therefore, do not assume that all patients that are on Digoxin are being treated for A-fib. Amniodarone and other are being treated for A-fib. Amniodarone and other antiarrhythmic medications are used to treat for A-fib and antiarrhythmic medications are used to treat for A-fib and other arrhythmias. These antiarrhythmics should be other arrhythmias. These antiarrhythmics should be recognized as such as compared to Digoxin and recognized as such as compared to Digoxin and anticoagulants.anticoagulants.

Arrhythmia Type – Vtach/Vfib (New)Arrhythmia Type – Vtach/Vfib (New)

Indicate whether sustained ventricular tachycardia Indicate whether sustained ventricular tachycardia or fibrillation is present within two weeks of the or fibrillation is present within two weeks of the procedure. procedure. CCORP suggests rhythm to be >30 CCORP suggests rhythm to be >30 seconds or require cardioversionseconds or require cardioversion..

STS Clarification: V-tach rhythm must be STS Clarification: V-tach rhythm must be sustained/persistent or paroxysmal sufficient as sustained/persistent or paroxysmal sufficient as to require some type of intervention to require some type of intervention (pharmacological and/or electrical) to interrupt (pharmacological and/or electrical) to interrupt and cease the arrhythmia.and cease the arrhythmia.

Arrhythmia Type – Third Degree Heart Arrhythmia Type – Third Degree Heart Block (New)Block (New)

STS Clarification: Heart block is applicable only if STS Clarification: Heart block is applicable only if the patient has or did have 3rd degree heart the patient has or did have 3rd degree heart block (complete heart block) within two weeks of block (complete heart block) within two weeks of the surgical procedure.the surgical procedure.

Clarification: If a pacer pt. for HB is in Sinus Rhythm Clarification: If a pacer pt. for HB is in Sinus Rhythm 2 weeks prior to surgery, code Arrhythmia = Yes 2 weeks prior to surgery, code Arrhythmia = Yes and Arrhythmia Type HB = No.and Arrhythmia Type HB = No.

Arrhythmia Type – Afib/Aflutter (New)Arrhythmia Type – Afib/Aflutter (New)

Indicate whether atrial fibrillation or flutter is Indicate whether atrial fibrillation or flutter is present within two weeks of the procedure.present within two weeks of the procedure.

STS Clarification: The pre-op arrhythmia is present STS Clarification: The pre-op arrhythmia is present within two weeks of the procedure, whether within two weeks of the procedure, whether chronic, new onset, stable or unstable. The chronic, new onset, stable or unstable. The patient may be receiving prescribed medication.patient may be receiving prescribed medication.

Clarification: If a pacer pt. for Afib is in Sinus Clarification: If a pacer pt. for Afib is in Sinus Rhythm 2 weeks prior to surgery, code Arrhythmia Rhythm 2 weeks prior to surgery, code Arrhythmia = Yes and Arrhythmia Type AFib = No.= Yes and Arrhythmia Type AFib = No.

Number of Diseased Coronary Vessels Number of Diseased Coronary Vessels (Revised)(Revised)

Indicate the number of diseased major native coronary Indicate the number of diseased major native coronary vessel systems: LAD system, Circumflex system, vessel systems: LAD system, Circumflex system, and/or Right system with >=50% narrowing of any and/or Right system with >=50% narrowing of any vessel vessel preoperativelypreoperatively..

NOTE: Left main disease (>= 50%) is counted as TWO NOTE: Left main disease (>= 50%) is counted as TWO vessels (LAD and Circumflex). For example, left main vessels (LAD and Circumflex). For example, left main and right coronary artery (RCA) would count as three and right coronary artery (RCA) would count as three total.total.

Clarification: For valve misadventures where there is no Clarification: For valve misadventures where there is no disease but a single vessel bypass is performed, do not disease but a single vessel bypass is performed, do not report these cases to CCORP.report these cases to CCORP.

Number of Diseased Coronary VesselsNumber of Diseased Coronary Vessels

PDA

Marginal

DiagonalPosterolaterals


The number of vessels refers to the number of major The number of vessels refers to the number of major coronary arteries which are diseased. coronary arteries which are diseased.

Consider a major coronary artery as diseased if it or one of Consider a major coronary artery as diseased if it or one of its first order branches has a greater than or equal to 50% its first order branches has a greater than or equal to 50% stenosis. The three major coronary arteries and their first stenosis. The three major coronary arteries and their first order branches are 1) the left anterior descending (LAD) order branches are 1) the left anterior descending (LAD) with its branches the diagonals; 2) the circumflex (Cx) with its branches the diagonals; 2) the circumflex (Cx) with its branches the obtuse marginals (OM’s) or with its branches the obtuse marginals (OM’s) or circumflex marginals; and 3) the right coronary artery circumflex marginals; and 3) the right coronary artery (RCA) with its branch the posterior descending artery (RCA) with its branch the posterior descending artery (PDA). (PDA).


The STS now considers Left Main Disease to count as TWO The STS now considers Left Main Disease to count as TWO vessels–-encompassing the LAD and Circumflex (see NOTE vessels–-encompassing the LAD and Circumflex (see NOTE under definition column). As such, if the chart indicates that under definition column). As such, if the chart indicates that Left Main, LAD and Circumflex are all diseased, code the Left Main, LAD and Circumflex are all diseased, code the number of diseased vessels as TWO, so as not to double count number of diseased vessels as TWO, so as not to double count the Left Main. the Left Main.

When the posterior-descending artery (PDA) is supplied by the When the posterior-descending artery (PDA) is supplied by the circumflex (i.e., when the circumflex instead of the right circumflex (i.e., when the circumflex instead of the right coronary artery is dominant), standard practice is to count the coronary artery is dominant), standard practice is to count the PDA (but NOT the non-dominant RCA) as a major vessel. Thus, PDA (but NOT the non-dominant RCA) as a major vessel. Thus, a patient with stenosis of the LAD, an obtuse marginal branch a patient with stenosis of the LAD, an obtuse marginal branch off of the circumflex, and the PDA off of the circumflex would be off of the circumflex, and the PDA off of the circumflex would be coded as having 3 vessel disease.coded as having 3 vessel disease.


NOTE: the number of major arteries which are counted as NOTE: the number of major arteries which are counted as diseased may differ from the number of bypass grafts diseased may differ from the number of bypass grafts placed (e.g., a graft may be placed to a vessel with < placed (e.g., a graft may be placed to a vessel with < 50% stenosis or two grafts to the LAD and diagonal even 50% stenosis or two grafts to the LAD and diagonal even though both are part of a single major vessel).though both are part of a single major vessel).

Ejection Fraction (%) – (Revised)Ejection Fraction (%) – (Revised)

Indicate the percentage of the blood emptied from the Indicate the percentage of the blood emptied from the ventricle at the end of the contraction. Use the most ventricle at the end of the contraction. Use the most recent determination prior to the recent determination prior to the surgicalsurgical intervention intervention documented on a diagnostic reportdocumented on a diagnostic report. Valid values . Valid values range from 1.0 – 99.0. range from 1.0 – 99.0. NOTE – the official # on a NOTE – the official # on a report trumps the surgeon’s estimate.report trumps the surgeon’s estimate.

Clarification: If the EF or “left ventricular function” is Clarification: If the EF or “left ventricular function” is described qualitatively, enter as follows: normal = 60%, described qualitatively, enter as follows: normal = 60%, mildly reduced or good = 50%, mild = 45%, fair = 40%, mildly reduced or good = 50%, mild = 45%, fair = 40%, moderate = 30%, poor = 25% and severe = 20%. “Low moderate = 30%, poor = 25% and severe = 20%. “Low limit of normal” = 50%. If “mild to moderate” mean 30 limit of normal” = 50%. If “mild to moderate” mean 30 and 45% to get 37%.and 45% to get 37%.

Ejection Fraction (%) - ClarificationEjection Fraction (%) - Clarification

If the EF or “left ventricular function” is described qualitatively, If the EF or “left ventricular function” is described qualitatively, enter as follows: normal = 60%, mildly reduced or good = enter as follows: normal = 60%, mildly reduced or good = 50%, mild = 45%, fair = 40%, moderate = 30%, poor = 25% 50%, mild = 45%, fair = 40%, moderate = 30%, poor = 25% and severe = 20%. “Low limit of normal” = 50%. If “mild to and severe = 20%. “Low limit of normal” = 50%. If “mild to moderate” mean 30 and 45% to get 37%.moderate” mean 30 and 45% to get 37%.

Ejection fraction (EF) is an important predictor of risk. Make Ejection fraction (EF) is an important predictor of risk. Make every effort to obtain it when available. every effort to obtain it when available.

If a range of EF’s are given, enter the mean value (e.g. for If a range of EF’s are given, enter the mean value (e.g. for “30 to 35%”, enter “32” - the system has no space for 32.5). “30 to 35%”, enter “32” - the system has no space for 32.5).

Ejection Fraction Method (Revised)Ejection Fraction Method (Revised)

Indicate how the ejection fraction measurement Indicate how the ejection fraction measurement information information was obtained preoperativelywas obtained preoperatively, including:, including:

2 = LV Gram, 2 = LV Gram,

3 = Radionucleotide, 3 = Radionucleotide,

4 = Estimate, 4 = Estimate,

5 = ECHO, 5 = ECHO,

6 = 6 = MRI/CT orMRI/CT or

9 = 9 = OtherOther

NOTE: NO harvest coding with #’s 1, 7 and 8NOTE: NO harvest coding with #’s 1, 7 and 8

Ejection Fraction Method - ClarificationEjection Fraction Method - Clarification

Since operative conditions may artifactually alter ejection Since operative conditions may artifactually alter ejection fraction and mitral regurgitation, readings from fraction and mitral regurgitation, readings from preoperative trans-thoracic echocardiograms are generally preoperative trans-thoracic echocardiograms are generally more accurate than those from trans-esophageal more accurate than those from trans-esophageal echocardiograms (TEE’s) done during surgery. Use the echocardiograms (TEE’s) done during surgery. Use the last determination of EF prior to surgery. “Estimated” last determination of EF prior to surgery. “Estimated” LVEFs based on inspection of an echocardiogram or LV LVEFs based on inspection of an echocardiogram or LV gram is acceptable if documented in the written report for gram is acceptable if documented in the written report for that study. Calculated or quantified LVEF based on that study. Calculated or quantified LVEF based on planimetry is not required. planimetry is not required. LVEFs which are guessed at LVEFs which are guessed at based on clinical presentation (and not based on based on clinical presentation (and not based on imaging of the ventricle) are not acceptable.imaging of the ventricle) are not acceptable.

Mean Pulmonary Artery Pressure Done Mean Pulmonary Artery Pressure Done (New)(New)

Indicate whether the mean pulmonary artery Indicate whether the mean pulmonary artery pressure in mmHg, was recorded from pressure in mmHg, was recorded from catheterization data or Swan-Ganz catheter catheterization data or Swan-Ganz catheter BEFORE the induction of anesthesia.BEFORE the induction of anesthesia.

Mean Pulmonary Artery Pressure Done – Mean Pulmonary Artery Pressure Done – Clarification Clarification

STS Clarifications: Elevated pulmonary artery pressures STS Clarifications: Elevated pulmonary artery pressures are indicative of pulmonary hypertension, mitral valve are indicative of pulmonary hypertension, mitral valve disease and other pulmonary/cardiac diseases. disease and other pulmonary/cardiac diseases.

Normal mean pulmonary artery pressure readings are Normal mean pulmonary artery pressure readings are between 9-17mm of pressure. If there are not any PA between 9-17mm of pressure. If there are not any PA pressure readings recorded or available from heart cath pressure readings recorded or available from heart cath –one may use PA pressure values from Swan Ganz –one may use PA pressure values from Swan Ganz Catheter inserted for surgery. If you capture the PA Catheter inserted for surgery. If you capture the PA value from the Swan Ganz, it must be obtained prior to value from the Swan Ganz, it must be obtained prior to anesthesia induction.anesthesia induction.

Pulmonary Artery Mean (New)Pulmonary Artery Mean (New)

• The mean pulmonary artery pressure in mmHg, The mean pulmonary artery pressure in mmHg, recorded from catheterization data or Swan-Ganz recorded from catheterization data or Swan-Ganz catheter BEFORE the induction of anesthesia. catheter BEFORE the induction of anesthesia. Valid values are between 1.0 and 99.0 mmHg.Valid values are between 1.0 and 99.0 mmHg.

Pulmonary Artery Mean - ClarificationPulmonary Artery Mean - Clarification

• STS Clarifications: Normal values are 9 – 17 mm Hg. Values STS Clarifications: Normal values are 9 – 17 mm Hg. Values reflect basic cardiopulmonary function. Lower values may reflect basic cardiopulmonary function. Lower values may represent hypovolemia or vascular dilatation, while higher represent hypovolemia or vascular dilatation, while higher values may represent volume overload or vascular values may represent volume overload or vascular constriction. Values may also be medication induced. constriction. Values may also be medication induced.

• The PA should be marked not done unless specifically a right The PA should be marked not done unless specifically a right heart cath was done or the patient has a pre-op PA catheter. heart cath was done or the patient has a pre-op PA catheter. Do not record the PA catheter number in the OR after Do not record the PA catheter number in the OR after anesthesia induction or use the LVEDP as a surrogate. anesthesia induction or use the LVEDP as a surrogate.

• When diagnostic heart caths are done on an outpatient basis, When diagnostic heart caths are done on an outpatient basis, most cardiovascular (CV) surgeons allow for cath data to be most cardiovascular (CV) surgeons allow for cath data to be considered current if they are performed within six months of considered current if they are performed within six months of the date of surgery.the date of surgery.

Mitral Insufficiency (Revised)Mitral Insufficiency (Revised)

0 = None; 1 = Trivial; 2 = Mild; 3 = Moderate; 0 = None; 1 = Trivial; 2 = Mild; 3 = Moderate; 4 = Severe; 4 = Severe; 5 = N/A5 = N/A..

Indicate whether there is evidence of mitral valve Indicate whether there is evidence of mitral valve regurgitation. regurgitation. Enter level of valve function Enter level of valve function associated with highest risk (i.e. worst associated with highest risk (i.e. worst performance). Enter highest level recorded in performance). Enter highest level recorded in chart. If data not available or study chart. If data not available or study suboptimal, enter N/A. suboptimal, enter N/A.

Mitral Insufficiency - ClarificationMitral Insufficiency - Clarification

If a range of MR is given, enter the higher value If a range of MR is given, enter the higher value (e.g. for “2 (mild) to 3 (moderate)” enter “3” or (e.g. for “2 (mild) to 3 (moderate)” enter “3” or moderate). Since operative conditions may moderate). Since operative conditions may artifactually alter ejection fraction and mitral artifactually alter ejection fraction and mitral regurgitation, readings from preoperative trans-regurgitation, readings from preoperative trans-thoracic echocardiograms are generally more thoracic echocardiograms are generally more accurate than those from trans-esophageal accurate than those from trans-esophageal echocardiograms (TEE’s) done during surgery.echocardiograms (TEE’s) done during surgery.

Status of Procedure (Revised)Status of Procedure (Revised)

Indicate the clinical status of the patient prior to Indicate the clinical status of the patient prior to entering the entering the operating room:operating room:

Emergent Salvage: The patient is undergoing Emergent Salvage: The patient is undergoing cardiopulmonary resuscitation en route to the operating cardiopulmonary resuscitation en route to the operating room or prior to anesthesia induction. room or prior to anesthesia induction.

Clarification: If the cath was elective, the status is usually Clarification: If the cath was elective, the status is usually elective, even if the patient was admitted for surgery after elective, even if the patient was admitted for surgery after cath unless 1) clinical decompensation meeting definition of cath unless 1) clinical decompensation meeting definition of urgent (eg, unstable angina) or 2) left main >=80%.urgent (eg, unstable angina) or 2) left main >=80%.


Emergent: Emergent: Patients requiring emergency operations will have Patients requiring emergency operations will have ongoing, refractory (difficult, complicated, and/or unmanageable) ongoing, refractory (difficult, complicated, and/or unmanageable) unrelenting cardiac compromise, with or without hemodynamic unrelenting cardiac compromise, with or without hemodynamic instability, and not responsive to any form of therapy except cardiac instability, and not responsive to any form of therapy except cardiac surgery. An emergency operation is one in which there should be surgery. An emergency operation is one in which there should be no delay in providing operative intervention.no delay in providing operative intervention.

The patient’s clinical status includes any of the following:The patient’s clinical status includes any of the following:

a. Ischemic dysfunction (any of the following): (1) Ongoing ischemia a. Ischemic dysfunction (any of the following): (1) Ongoing ischemia including rest angina despite maximal medical therapy (medical and/or including rest angina despite maximal medical therapy (medical and/or IABP)); (2) Acute Evolving Myocardial Infarction within 24 hours before IABP)); (2) Acute Evolving Myocardial Infarction within 24 hours before surgery; or (3) pulmonary edema requiring intubation.surgery; or (3) pulmonary edema requiring intubation.

b. Mechanical dysfunction (either of the following): (1) shock with b. Mechanical dysfunction (either of the following): (1) shock with circulatory support; or (2) shock without circulatory support.circulatory support; or (2) shock without circulatory support.


Urgent: Procedure required during same hospitalization in Urgent: Procedure required during same hospitalization in order to minimize chance of further clinical deterioration. order to minimize chance of further clinical deterioration. Examples include but are not limited to: Worsening, Examples include but are not limited to: Worsening, sudden chest pain, CHF, acute myocardial infarction sudden chest pain, CHF, acute myocardial infarction (AMI), anatomy, IABP, unstable angina (USA) with (AMI), anatomy, IABP, unstable angina (USA) with intravenous (IV) nitroglycerin (NTG) or rest angina.intravenous (IV) nitroglycerin (NTG) or rest angina.

Elective: The patient's Elective: The patient's cardiac functioncardiac function has been stable in has been stable in the days or weeks prior to the operation. The procedure the days or weeks prior to the operation. The procedure could be deferred without increased risk of compromised could be deferred without increased risk of compromised cardiac outcome.cardiac outcome.

Status of Procedure – ClarificationStatus of Procedure – Clarification

Status refers to the patient’s condition immediately before Status refers to the patient’s condition immediately before surgery; it should not reflect instability which occurs after the surgery; it should not reflect instability which occurs after the induction of anesthesia or the operative risk but rather how induction of anesthesia or the operative risk but rather how expediently surgery must be performed. Thus some elective expediently surgery must be performed. Thus some elective patients may be at higher risk than urgent patients; for example, patients may be at higher risk than urgent patients; for example, an elderly patient with an ejection fraction of 20% and COPD an elderly patient with an ejection fraction of 20% and COPD operated on electively compared to a young patient with a operated on electively compared to a young patient with a normal ejection fraction who has ongoing unstable angina.normal ejection fraction who has ongoing unstable angina.

RULE OF THUMB: Elective – waits at home. Urgent – waits in RULE OF THUMB: Elective – waits at home. Urgent – waits in hospital. Emergent – cannot wait or is not safe to wait. hospital. Emergent – cannot wait or is not safe to wait. Emergent Salvage – no pulse.Emergent Salvage – no pulse.


Elective surgeries are performed on patients whose cardiac Elective surgeries are performed on patients whose cardiac function has been stable. They are usually scheduled at function has been stable. They are usually scheduled at least one day prior to surgery, and the clinical picture allows least one day prior to surgery, and the clinical picture allows discharge from the hospital with readmission for surgery discharge from the hospital with readmission for surgery later. later.

Urgent surgeries are performed on patients whose medical Urgent surgeries are performed on patients whose medical condition requires continuous hospitalization prior to CABG. condition requires continuous hospitalization prior to CABG. A critical feature that distinguishes urgent from elective A critical feature that distinguishes urgent from elective patients is that urgent patients cannot be safely discharged patients is that urgent patients cannot be safely discharged prior to their CABG, but they can safely await ABG in the prior to their CABG, but they can safely await ABG in the hospital. An intra-aortic balloon pump or IV nitroglycerin may hospital. An intra-aortic balloon pump or IV nitroglycerin may be part of treatment.be part of treatment.


Emergent surgeries are performed on patients whose condition Emergent surgeries are performed on patients whose condition dictates that the surgery be performed within several hours to dictates that the surgery be performed within several hours to prevent morbidity or death. These cases should take prevent morbidity or death. These cases should take precedence over an elective case, cause a new operating room precedence over an elective case, cause a new operating room to be opened, or be done at night or on a weekend if necessary. to be opened, or be done at night or on a weekend if necessary. A critical feature which distinguishes emergent from urgent A critical feature which distinguishes emergent from urgent patients is that emergent patients cannot safely delay CABG patients is that emergent patients cannot safely delay CABG even while they are in the hospital. Emergent cases are rare. even while they are in the hospital. Emergent cases are rare.

Salvage surgeries are performed on a patient undergoing CPR Salvage surgeries are performed on a patient undergoing CPR en route to operating room or in the operating room prior to en route to operating room or in the operating room prior to induction of anesthesia. Patient is pulseless within hour prior to induction of anesthesia. Patient is pulseless within hour prior to surgery.surgery.

Emergent Reason (New)Emergent Reason (New)

• Patients requiring emergency operations will have Patients requiring emergency operations will have ongoing, refractory (difficult, complicated, and/or ongoing, refractory (difficult, complicated, and/or (unmanageable) unrelenting cardiac compromise, with (unmanageable) unrelenting cardiac compromise, with or without hemodynamic instability, and not responsive or without hemodynamic instability, and not responsive to any form of therapy except cardiac surgery. An to any form of therapy except cardiac surgery. An emergency operation is one in which there should be emergency operation is one in which there should be no delay in providing operative intervention. no delay in providing operative intervention.

• Indicate which one of the following applies as the Indicate which one of the following applies as the reason why the patient had Emergent Status? reason why the patient had Emergent Status?

Emergent Reason (New)Emergent Reason (New)

• 1 = Shock with circulatory support1 = Shock with circulatory support• 2 = Shock without circulatory support2 = Shock without circulatory support• 3 = Pulmonary edema requiring intubation3 = Pulmonary edema requiring intubation• 4 = Acute Evolving Myocardial Infarction within 24 hours 4 = Acute Evolving Myocardial Infarction within 24 hours

before surgerybefore surgery• 5 = Ongoing ischemia including rest angina despite 5 = Ongoing ischemia including rest angina despite

maximal medical therapy (medical and/or IABP)maximal medical therapy (medical and/or IABP)• 6 = Valve Dysfunction - Acute Native or Prosthetic6 = Valve Dysfunction - Acute Native or Prosthetic• 7 = Aortic Dissection7 = Aortic Dissection• 8 = Angiographic Accident8 = Angiographic Accident• 9 = Cardiac Trauma9 = Cardiac Trauma

CPB Utilization – Combination CPB Utilization – Combination (Revised)(Revised)

• Whether the combination procedure from Whether the combination procedure from off-off-pump to on-pumppump to on-pump was a planned or an was a planned or an unplanned conversion:unplanned conversion:

• 1) Planned: The surgeon intended to treat with 1) Planned: The surgeon intended to treat with any of the combination options described in “CPB any of the combination options described in “CPB Utilization”Utilization”

• 2) Unplanned: The surgeon did not intend to 2) Unplanned: The surgeon did not intend to treat with any of the combination options treat with any of the combination options described in “CPB Utilization”described in “CPB Utilization”

Left Anterior Descending Artery Left Anterior Descending Artery Bypassed (New)Bypassed (New)

Indicate whether any part of the Left Anterior Descending Indicate whether any part of the Left Anterior Descending artery (Proximal; Mid; Distal; Diagonal) was bypassed artery (Proximal; Mid; Distal; Diagonal) was bypassed for this surgical intervention. for this surgical intervention.

Valid Values: 1 = Yes; 2 = NoValid Values: 1 = Yes; 2 = No

Valve Procedure Done (New)Valve Procedure Done (New)

Indicate whether a surgical procedure was done on the Indicate whether a surgical procedure was done on the Aortic, Mitral, Tricuspid or Pulmonic valves.Aortic, Mitral, Tricuspid or Pulmonic valves.

Valid Values: 1 = Yes; 2 = NoValid Values: 1 = Yes; 2 = No

Aortic Valve Procedure (New)Aortic Valve Procedure (New)

Indicate whether a surgical procedure was done or not done on the Indicate whether a surgical procedure was done or not done on the Aortic Valve. Aortic Valve.

• 1 = No1 = No• 2 = Replacement2 = Replacement• 3 = Repair/Reconstruction3 = Repair/Reconstruction• 4 = Root Reconstruction with Valve Conduit4 = Root Reconstruction with Valve Conduit• 5 = Root Reconstruction with Valve Sparing 5 = Root Reconstruction with Valve Sparing • 7 = Resection Sub-Aortic Stenosis7 = Resection Sub-Aortic Stenosis• 8 = Replacement + Aortic Graft Conduit (not a valve conduit)8 = Replacement + Aortic Graft Conduit (not a valve conduit)• 9 = Resuspension Aortic Valve with Replacement of Ascending 9 = Resuspension Aortic Valve with Replacement of Ascending

aortaaorta• 10 = Resuspension Aortic Valve without Replacement of 10 = Resuspension Aortic Valve without Replacement of

Ascending aortaAscending aorta

Mitral Valve Procedure (New)Mitral Valve Procedure (New)

Indicate whether a surgical procedure was done or not Indicate whether a surgical procedure was done or not done on the Mitral Valve. done on the Mitral Valve.

• 1 = No1 = No• 2 = Annuloplasty only2 = Annuloplasty only• 3 = Replacement3 = Replacement• 4 = Reconstruction with Annuloplasty4 = Reconstruction with Annuloplasty• 5 = Reconstruction without Annuloplasty 5 = Reconstruction without Annuloplasty

Tricuspid Valve Procedure (New)Tricuspid Valve Procedure (New)

Indicate whether a surgical procedure was done or not Indicate whether a surgical procedure was done or not done on the Tricuspid Valve. done on the Tricuspid Valve.

• 1 = No1 = No• 2 = Annuloplasty only2 = Annuloplasty only• 3 = Replacement3 = Replacement• 4 = Reconstruction with Annuloplasty4 = Reconstruction with Annuloplasty• 5 = Reconstruction without Annuloplasty 5 = Reconstruction without Annuloplasty • 6 = Valvectomy6 = Valvectomy

Pulmonic Valve Procedure (New)Pulmonic Valve Procedure (New)

Indicate whether a surgical procedure was done or not Indicate whether a surgical procedure was done or not done on the Pulmonic Valve. done on the Pulmonic Valve.

• 1 = No1 = No• 2 = Replacement2 = Replacement• 3 = Reconstruction3 = Reconstruction

Re-operation For Bleed/Tamponade Re-operation For Bleed/Tamponade (Revised)(Revised)

Indicate whether the patient Indicate whether the patient returned to the operating returned to the operating room for mediastinalroom for mediastinal bleeding/tamponade. bleeding/tamponade.

Re-operation For Bleed/Tamponade Re-operation For Bleed/Tamponade ClarificationClarificationSTS Clarifications: STS Clarifications:

• Do not capture reopening of the chest or situations of Do not capture reopening of the chest or situations of excessive bleeding that occur prior to the patient leaving the excessive bleeding that occur prior to the patient leaving the operating room at the time of the primary procedure. Do not operating room at the time of the primary procedure. Do not include medically (nonoperatively) treated excessive post-include medically (nonoperatively) treated excessive post-operative bleeding/tamponade events. The patient must return operative bleeding/tamponade events. The patient must return to the operating room suite for surgical intervention.to the operating room suite for surgical intervention.

• Include patients that return to an OR suite or equivalentInclude patients that return to an OR suite or equivalent• OR environment (i.e., ICU setting) as identified by your OR environment (i.e., ICU setting) as identified by your

institution, that require surgical re-intervention to institution, that require surgical re-intervention to investigate/correct bleeding/tamponade. Include only those investigate/correct bleeding/tamponade. Include only those bleeding/tamponade interventions that pertain to the bleeding/tamponade interventions that pertain to the mediastinum or thoracic cavity.mediastinum or thoracic cavity.

Re-operation For Graft Occlusion Re-operation For Graft Occlusion (Revised)(Revised)

Indicate whether the patient Indicate whether the patient returned to the operating returned to the operating room for coronaryroom for coronary graft occlusion graft occlusion due to acute due to acute closure, thrombosis, technical or embolic originclosure, thrombosis, technical or embolic origin..

Re-operation For Graft Occlusion Re-operation For Graft Occlusion ClarificationClarification

• STS Clarification:STS Clarification: RequiresRequires a return to an OR suite to a return to an OR suite to capture as a complication. capture as a complication.

Deep Sternal Wound Infection Deep Sternal Wound Infection (Revised)(Revised)

Indicate whether patient, within Indicate whether patient, within 30 days postoperatively30 days postoperatively, , had a deep sternal infection involving muscle, bone, had a deep sternal infection involving muscle, bone, and/or mediastinum REQUIRING OPERATIVE and/or mediastinum REQUIRING OPERATIVE INTERVENTION. INTERVENTION. Code according to STS guidelines Code according to STS guidelines and newsletter clarification (May 2008).and newsletter clarification (May 2008).

Must have ALL of the following conditions:Must have ALL of the following conditions:• (i ) Wound opened with excision of tissue (I&D) or re-(i ) Wound opened with excision of tissue (I&D) or re-

exploration of mediastinumexploration of mediastinum• (ii) Positive culture(ii) Positive culture• (iii) Treatment with antibiotics(iii) Treatment with antibiotics

Postoperative Stroke (Revised)Postoperative Stroke (Revised)

Indicate whether the patient has Indicate whether the patient has a postoperative stroke a postoperative stroke (i.e., any confirmed neurological deficit of abrupt (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in cerebral blood onset caused by a disturbance in cerebral blood supply) that did not resolve within 24 hours. supply) that did not resolve within 24 hours.

• STS Clarification:STS Clarification: Central events are caused by Central events are caused by embolic or hemorrhagic events. Neurological deficits embolic or hemorrhagic events. Neurological deficits such as confusion, delirium and/or encephalopatic such as confusion, delirium and/or encephalopatic (anoxic or metabolic) events are not to be coded in this (anoxic or metabolic) events are not to be coded in this field.field.

Prolonged Ventilation (Revised)Prolonged Ventilation (Revised)

Indicate whether the patient Indicate whether the patient had prolonged pulmonary ventilator had prolonged pulmonary ventilator > 24 hours.> 24 hours. Include (but not limited to) causes such as ARDS, Include (but not limited to) causes such as ARDS, pulmonary edema, and/or any patient requiring mechanical pulmonary edema, and/or any patient requiring mechanical ventilation > 24 hours postoperatively. ventilation > 24 hours postoperatively. Time is calculated from Time is calculated from the point of leaving the OR and NOT when the patient was the point of leaving the OR and NOT when the patient was initially intubated.initially intubated.

• STS ClarificationSTS Clarification: : • A total of 24 hours, include initial and additional hours of A total of 24 hours, include initial and additional hours of

mechanical ventilation.mechanical ventilation.• Do not include the hours ventilated if a patient returns to the Do not include the hours ventilated if a patient returns to the

operating room suite and requires re intubation as part of general operating room suite and requires re intubation as part of general anesthesia.anesthesia.

Postoperative Dialysis Requirement Postoperative Dialysis Requirement (New)(New)

Indicate whether the patient had a new requirement for Indicate whether the patient had a new requirement for dialysis postoperatively, which may include hemodialysis, dialysis postoperatively, which may include hemodialysis, peritoneal dialysis, and any form of ultrafiltration. peritoneal dialysis, and any form of ultrafiltration.

• STS ClarificationSTS Clarification: : • May include either hemo or peritoneal dialysis. This May include either hemo or peritoneal dialysis. This

includes a one time need for dialysis as well as includes a one time need for dialysis as well as implementation of longer term therapy. If the patient was implementation of longer term therapy. If the patient was on preoperative peritoneal dialysis and moved to on preoperative peritoneal dialysis and moved to hemodialysis postoperatively, this does not constitute a hemodialysis postoperatively, this does not constitute a worsening of the condition and should not be coded as worsening of the condition and should not be coded as an event.an event.

• IF Pre-op Dialysis = Yes, Post-op Dialysis = NoIF Pre-op Dialysis = Yes, Post-op Dialysis = No

Postoperative Atrial Fibrillation (New)Postoperative Atrial Fibrillation (New)

Indicate whether the patient had a new onset of atrial Indicate whether the patient had a new onset of atrial fibrillation/flutter (AF) requiring treatment. Does not fibrillation/flutter (AF) requiring treatment. Does not include recurrence of AF which had been present include recurrence of AF which had been present preoperatively.preoperatively.

Clarification: If history of AFib (Arrhythmia = Yes) AND Clarification: If history of AFib (Arrhythmia = Yes) AND patient is in Sinus Rhythm 2 weeks prior to surgery patient is in Sinus Rhythm 2 weeks prior to surgery (Arrhythmia type Afib = No), (Arrhythmia type Afib = No), code Post-op AFib = Nocode Post-op AFib = No

Postoperative Atrial Fibrillation Postoperative Atrial Fibrillation ClarificationClarification

STS Clarifications: STS Clarifications: • DO NOT include patients that had preoperative atrial DO NOT include patients that had preoperative atrial

fibrillation (treated or nontreated). The event must be of fibrillation (treated or nontreated). The event must be of new origin. new origin.

• The intent of this field is to capture new onset A Fib The intent of this field is to capture new onset A Fib that requires treatment and NOT to capture a that requires treatment and NOT to capture a reoccurrence of A Fib which had been present pre-op. reoccurrence of A Fib which had been present pre-op.

Questions?Questions?

And answers!And answers!

Contact us…..Contact us…..

• Healthcare Outcomes CenterHealthcare Outcomes Center

[email protected]@oshpd.ca.gov

(916) 326-3861(916) 326-3861

• Pierre WashingtonPierre Washington


(916) 326-3878(916) 326-3878

• Victor MuhVictor Muh


(916) 326-3877(916) 326-3877

• Julie WestJulie West


(916) 326-3879(916) 326-3879

• Holly HoeghHolly Hoegh


(916) 326-3868(916) 326-3868

healthcare outcomes center

Documents