Long Term Follow-up. 6 Month 1 Year Annual enter year #: What is the assessment date: / / Unknown. Is the patient alive? Yes No

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1 Long Term Follow-up 6 Month 1 Year Annual enter year #: What is the assessment date: / / Unknown Is the patient alive? Yes No Was an exam performed by a bariatric physician or PA/NP? Yes No Was the patient seen by any clinician? Yes No GENERAL Height: cm in Unknown Was anticoagulation initiated for presumed/confirmed DVT/PE? Yes No Was an incisional hernia noted on exam? Yes No COMORBIDITY Sleep Apnea GERD req. meds. Hyperlipidemia Hypertension Diabetes Yes No Not Documented Yes No Not Documented Yes No Not Documented Yes No Not Documented If yes, # of antihypertensive meds: Yes No Not Documented If yes, select: Non-insulin Insulin 1 MBSAQIP Appendix C- January 1, 2017

2 ATTEMPTS BY THE BARIATRIC CENTER TO CONTACT PATIENT Was a follow-up appointment made but patient did not show for appointment? Yes No Was a phone call placed to the patient? Was a letter sent to the patient? Once Twice Never Once Twice Never Was the patient s care transferred to another bariatric specialist? Yes No If yes, please list name. Name: Is patient refusing long-term follow-up? Yes No Is the patient lost to follow-up? Yes No Mortality Information Date of Death / / Unknown Was the Death Likely Related to the Operation? Yes No Most Likely Cause of Death: Anastomotic/Staple Line Leak GI Perforation Other Abdominal Sepsis Strictures/Stomal Obstruction Intestinal Obstruction Gastric Distention Fluid, Electrolyte, or Nutritional depletion Anastomotic Ulcer Gastro-Gastric Fistula Gallstone Disease Wound Infection/Evisceration Internal Hernia Incisional Hernia Bleeding Vein Thrombosis Requiring Therapy Pulmonary Embolism Pneumonia Other Respiratory Failure Infection/Fever Band Slippage/Prolapse Band Erosion LAGB Port, Tubing or Band problem Bile Reflux Gastritis Other Comments 2 MBSAQIP Appendix C- January 1, 2017

3 HOSPITAL READMISSIONS Did the patient have a readmission? Yes No Readmission #1 Readmission Date: / / Unknown Discharge Date: / / Unknown Was this readmission likely related to a bariatric procedure? Yes No Most likely reason for admission Comments: Readmission #2 Readmission Date: / / Unknown Discharge Date: / / Unknown N/A Was this readmission likely related to a bariatric procedure? Yes No Most likely reason for admission Comments: Readmission #3 Readmission Date: / / Unknown Discharge Date: / / Unknown N/A Was this readmission likely related to a bariatric procedure? Yes No Most likely reason for admission Comments: for Readmission Nausea and Vomiting, Fluid, Electrolyte, or Nutritional Cardiac N.O.S. (arrhythmias, CHF) Depletion Anastomotic/Staple Line Leak Chest Pain (cardiac enzymes not required to be positive) Anastomotic Ulcer Myocardial Infarction Band Slippage/Prolapse Abdominal Pain, Not Otherwise Specified Band Erosion Intestinal Obstruction Bleeding Other Abdominal Sepsis (diverticulitis, pancreatitis, intraabdominal abscess) Gastric Distention CVA Gastro-Gastric Fistula Psychiatric-Related GI Perforation Nephrolithiasis Internal Hernia Renal Insufficiency LAGB - Port, Tubing or Band Problem Bile Reflux Gastritis Strictures/Stomal Obstruction Gallstone Disease Incisional Hernia Infection/Fever Wound Infection/Evisceration Medication-Related Other Respiratory Failure (including pleural effusions) Musculoskeletal Pain Pneumonia Other Pulmonary Embolism Planned Surgery Shortness of Breath (without diagnosis of PE) Vein Thrombosis Requiring Therapy 3 MBSAQIP Appendix C- January 1, 2017

4 REOPERATIONS/INTERVENTIONS Did the Patient have a Reoperation/Intervention? Yes No Reoperation #1 Reoperation (see table below) CPT Code for Reoperations: Unknown Most likely reason for reoperation (enter code from table below) Date Performed / / Unknown Was this reoperation likely related to a metabolic or bariatric procedure? Yes No Reoperation #2 Reoperation (see table below) CPT Code for Reoperations: Unknown Most likely reason for reoperation (enter code from table below) Date Performed / / Unknown Was this reoperation likely related to a metabolic or bariatric procedure? Yes No Reoperation #3 Reoperation (see table below) CPT Code for Reoperations: Unknown Most likely reason for reoperation (enter code from table below) Date Performed / / Unknown Was this reoperation likely related to a metabolic or bariatric procedure? Yes No Reoperations Operative Drain Placement Gastrostomy Tube (G-tube) Placement Jejunostomy Tube (J-tube) Placement Anastomotic Revision Band Removal Band Tubing or Port Revision Band Placement Internal Hernia Repair Incisional Hernia Repair Cholecystectomy Bowel Resection Re-exploration Tracheostomy (Open or Percutaneous) Other-Abdominal Other Reoperation 4 MBSAQIP Appendix C- January 1, 2017

5 INTERVENTIONS Intervention #1 Intervention (see table below) Most likely reason for intervention (enter code from table below) Date Performed / / Unknown Was this intervention likely related to a metabolic or bariatric procedure? Yes No Intervention #2 Intervention (see table below) Most likely reason for intervention (enter code from table below) Date Performed / / Unknown Was this intervention likely related to a metabolic or bariatric procedure? Yes No Intervention #3 Intervention (see table below) Most likely reason for intervention (enter code from table below) Date Performed / / Unknown Was this intervention likely related to a metabolic or bariatric procedure? Yes No Interventions Diagnostic Endoscopy Therapeutic Endoscopy with Stent Placement/Retrieval Therapeutic Endoscopy with Dilation (no Stent) Therapeutic Endoscopy to control Bleeding Therapeutic Endoscopy with Stoma Resizing Therapeutic Endoscopy with Gastro-Gastric Fistula Closure Therapeutic Endoscopy with Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement Therapeutic Endoscopy with Band Removal Therapeutic Endoscopy with ERCP Therapeutic Endoscopy with Other Therapeutic Endoscopy Intraluminal Therapeutic Procedure -Planned/Scheduled Intragastric Balloon Removal per Protocol Intraluminal Therapeutic Procedure- Intragastric Balloon Intolerance Intraluminal Therapeutic Procedure- Intragastric Balloon Rupture Intraluminal Therapeutic Procedure - Obstruction Intraluminal Therapeutic Procedure - Aspiration Intraluminal Therapeutic Procedure - Perforation Intraluminal Therapeutic Procedure - Bleeding Intraluminal Therapeutic Procedure- Gastric Ulcer Placement of Percutaneous Drain Inferior Vena Cava (IVC) Filter Placement Inferior Vena Cava (IVC) Filter Retrieval Other Intervention 5 MBSAQIP Appendix C- January 1, 2017

6 for Reoperation/Intervention Nausea and Vomiting, Fluid, Electrolyte, or Nutritional Depletion Anastomotic/Staple Line Leak Anastomotic Ulcer Band Slippage/Prolapse Band Erosion Bleeding Gastric Distention Gastro-Gastric Fistula GI Perforation Internal Hernia LAGB - Port, Tubing or Band Problem Strictures/Stomal Obstruction Incisional Hernia Wound Infection/Evisceration Other Respiratory Failure (including pleural effusions) Pneumonia Pulmonary Embolism Shortness of Breath (without diagnosis of PE) Cardiac N.O.S. (arrhythmias, CHF) Chest Pain (cardiac enzymes not required to be positive) Myocardial Infarction Abdominal Pain, Not Otherwise Specified Intestinal Obstruction Other Abdominal Sepsis (diverticulitis, pancreatitis, intraabdominal abscess) CVA Psychiatric-Related Nephrolithiasis Renal Insufficiency Bile Reflux Gastritis Gallstone Disease Infection/Fever Medication-Related Musculoskeletal Pain Other Planned Surgery Vein Thrombosis Requiring Therapy 6 MBSAQIP Appendix C- January 1, 2017

7 PATIENT CONTACT MANAGEMENT MBSAQIP Case Number: IDN: Name: 7 MBSAQIP Appendix C- January 1, 2017