1. JULY 2012 UPDATES

2. CHANGE IN CARDIAC RISK CLASSIFICATION CODING PROCESS AND UTILIZATION OF THE PROVIDED CARDIAC ICD-9 CODES AND DESCRIPTIONS LIST. Cardiac Variable

3. Goals The SCR, in reviewing their chart, will be able to easily identify and recognize the documentation To correctly classify the cardiac defect without needing to spend extensive time and effort in researching the cardiac history of the patient.

4. Rationale The intent of the cardiac variable is to describe the cardiac risk factor classification so that it can be consistent over all sites.

5. Cardiac Risk Factors Classify the cardiac risk factors into one of the following categories based on present cardiac disease or a history of cardiac disease No risk factors (defaults to no risk factor) Minor risk factors Major risk factors Severe risk factors

6. Cardiac Risk Factor ICD 9 Diagnosis Code List The chart provides guidance to help identify the correct cardiac risk factor category, it is not fully inclusive/exclusive. Record cardiac diagnosis and ICD-9 diagnosis codes only from the list provided. Additional cardiac ICD-9 descriptions not found in the provided list need to be compiled by the SCRS and sent to clinical support to be forwarded on to the Data Definition Cardiac Subcommittee for review which may facilitate modification of the current list

7. Process Step 1: Assess the patient’s cardiac risk factors by chart abstraction, sources of information may include: history and physical exam cardiology notes echocardiogram anesthesia notes

8. Process Step 2: Apply the ICD-9 code from the list provided The descriptions found in the medical record may not have the exact ICD-9 codes in the provided list. (These codes were selected as a starting point) Only a narrative may be found or a different ICD-9 code Try to stay consistent with the description and ICD-9 code utilizing the provided list.

9. Applying ICD 9 Codes “Patient has delayed repolarization of the heart.” Is found in the medical record. Description indicates Long QT syndrome Apply ICD code 426.82 ___________________________________ ….”ductus arteriosus is open”… found in the medical record. Description would indicate PDA Apply ICD code 747

10. Applying ICD 9 Codes Congenital mitral stenosis 746.5(not on list)- stenosis of left atrioventricular orifice is in the medical record. Mitral valve stenosis 396.0 (on list) Apply 396.0 code

11. Process Step 3: Classify The “Cardiac Risk Factor” matching the code on the chart, for the provided risk. No Risk Factors Minor Cardiac Risk Factors Major Cardiac Risk Factors Severe Cardiac Risk Factors

12. Step 4: Enter all assigned codes on the list provided into the database.

13. Process Step 5: Additional cardiac ICD-9 descriptions not found in the provided list need to be compiled by the SCRS and sent to clinical support to be forwarded on to the Data Definition Cardiac Subcommittee for review which may facilitate modification of the current list. *The committee typically meets (once) a month so this process may take some time.

14. CARDIAC RISK FACTOR ICD 9 CODES Examples:

15. Narrative “Patient has delayed repolarization of the heart.” Is found in the medical record. Description indicates Long QT syndrome Apply ICD code 426.82 Classify as a minor cardiac risk factor ___________________________________ ….” isolated opening in the ventricular septum”… found in the medical record. Description would indicate VSD Apply ICD code 745.4 Classify as a minor risk factor

16. Exact Codes May Not be Provided Congenital mitral insufficiency 746.6- impaired functioning of mitral valve (code not on list) Mitral valve disorders 424.0 on the list. Apply code 424.0 Classify as minor cardiac risk factor according to chart

17. Minor vs. Major Risks Repaired PDA in medical record icd9 747 is listed as a minor cardiac risk factor category Same icd9 code 747 listed as an unrepaired PDA is listed in the major risk category.

18. Multiple Codes Record all cardiac ICD-9 diagnosis codes documented from the list below. If a patient has more than one cardiac risk factor categorize them into the highest risk factor group they fall into.

19. Multiple Codes An infant with: Tetralogy of Fallot (745.2), Major Risk Factor Pulmonary Atresia (747.3), Severe Risk Factor Should be placed in the severe category due to the pulmonary atresia.

20. Multiple Codes A Patient with: VSD (745.4), Minor Cardiac Risk Factor ASD (745.61),Minor Cardiac Risk Factor Single Ventricle (745.3), Severe Cardiac Risk Factor should be placed in the Severe category due to the single ventricle and all 3 icd codes should be entered into the database.

21. Multiple Codes An infant with: Bicuspid Aortic Valve (747.22), minor risk category VSD (745.69), minor risk category should be placed in the minor risk category because these are both listed in the minor risk category.

22. Multiple Codes Mitral valve stenosis 396.0 alone is listed in the minor category Mitral valve stenosis 396.0 with aortic valve stenosis or insufficiency 747.22 is classified as a major cardiac risk factor. Both ICD 9 codes would be recorded and you would classify the risk factor as major (the highest risk factor)

23. REVEIW Step 1 Assess the patient’s cardiac risk factors by chart abstraction Step 2: Apply the ICD-9 code from the list provided Step 3: Classify The “Cardiac Risk Factor” matching the code on the chart, for the provided risk. No Risk Factors Minor Cardiac Risk Factors Major Cardiac Risk Factors Severe Cardiac Risk Factors Step 4: Record all ICD-9 codes from the list provided that are listed in the medical record Step 5: Additional cardiac ICD-9 descriptions not found in the provided list need to be compiled by the SCRS and sent to clinical support to be forwarded on to the Data Definition Cardiac Subcommittee for review which may facilitate modification of the current list.

24. In Conclusion… The intent of creating the guidance list is to assist SCRs in achieving as much consistency as possible and to easily identify and recognize the documentation to correctly classify the cardiac defect. Remember to forward ICD-9 and descriptions not found in the provided list to clinical support to be forwarded on to the Data Definition Cardiac Subcommittee for review

25. UNPLANNED INTUBATION

26. Unplanned Re-intubation Unplanned Intubation: Patient required placement of an endotracheal tube or other similar breathing tube [Laryngeal Mask Airway (LMA), nasotracheal tube, etc.] and ventilator support which was not intended or planned. The variable intent is to capture all cause unplanned intubations, including but not limited to unplanned intubations for refractory hypotension, cardiac arrest, inability to protect airway. Accidental self extubation requiring reintubation would be assigned. Emergency tracheostomy would be assigned. Conversion from local or MAC anesthesia to general anesthesia with placement of a breathing tube and ventilator support, secondary to the patient not tolerating local or MAC anesthesia, in the absence of an emergency, would not be assigned. Example: Patient undergoes an inguinal hernia repair under MAC. Patient doesn’t tolerate the procedure well and is not cooperating; anesthesia switches to general and the patient is intubated; this scenario would not be assigned as an unplanned intubation; it is considered part of the normal safe management of anesthesia for the case.

27. WOUND DISRUPTION

28. Rational Wound disruption/dehiscence occurs to varying degrees and is clinically relevant, thus important to collect. Currently, however, only deep wound dehiscence is being recorded. On January 1, 2013, Pediatric NSQIP will be using a new definition which will include both superficial and deep wound disruption. Until that change occurs, Pediatric NSQIP will continue to collect only deep wound dehiscence. The guidelines below are provided so that questions which have arisen before about wounds other than abdominal wounds are answered. As a general rule, if separation of wound layers below the skin and subcutaneous tissues occurs, this is to be collected as deep wound dehiscence. Examples of tissues which may dehisce and may be considered deep wound disruptions are fascia, muscle, ribs, skull, sternum, tendon or ligament. Clinical examples by subspecialty have been included as well.

29. Postoperative Wound Disruption Dehiscence Variable: Wound Disruption/Dehiscence definition: Separation of the layers of a surgical wound, which may be partial or complete, with disruption of the fascia. Deep wound disruption/dehiscence: separation (or disruption) of the internal (deep) layer(s) of the surgical wound. Examples: fascia, muscle, ribs, skull, sternum, tendon or ligament Clinical examples: General Surgery: fascial separation of an abdominal wound recurrent gastrocutaneous fistula following closure of a g-tube site Neurosurgery: separation of the deepest layers of a myelomeningocele repair wound (with or without CSF leak) Orthopedics: separation of paravertebral muscle and/or fascia after laminectomy Urology: urethrocutaneous fistula after hypospadias repair Plastics/ENT: oronasal fistula after cleft palate repair Additional Guidance: ENT – A tympanoplasty (patch or graft) procedure doesn’t qualify as creating a surgical wound (typically performed for existing perforated tympanic membrane), therefore no wound disruption/dehiscence information is collected if this patch fails (e.g. recurrent tympanic membrane perforation). General Surgery – Ostomy: If an ostomy or stoma (enterostomy/colostomy) is brought out through a laparotomy wound and the wound is otherwise closed, separation of the deep layers of the wound will be collected as a wound disruption/dehiscence. If the ostomy is brought out through a separate incision that only allows the ostomy to protrude (i.e. the separate wound is not closed), the wound disruption/dehiscence variable will only apply to the laparotomy incision.

30. Q&A