mm / dd / yyyy Heart Failure 4040 à If Yes, New diagnosis 4050 (within 12 months) à If Yes, Etiology 4052 CAD - Stable Angina 4060

Transcription

1 MRN 1500 : Provider NPI 1550 : A. PATIENT DEMOGRAPHICS Encounter Date 1510 : Encounter TIN 1555 : NCDR PINNACLE Registry v1.6 (CardioEncounters) Data Collection Form Practice Innovation and Clinical Excellence Practice ID 1520 : Location ID 1530 : Patient new to the Practice 1560 : Patient Name(Last, First, MI) 2000, 2010, 2020 : SSN 2030 : Date of Birth 2050 : Race: (Check all that apply) Sex 2060 : O Male O Female Patient Zip 2200 : Insurance Payers: (Check all that apply) Medicaid (fee for service) 3030 Medicare (fee for service) 3028 Private Health Insurance 3020 Medicaid (managed care) 3031 Medicare (managed care) 3029 Military Health Care 3023 State Specific Plan (non-medicaid) 3024 Indian Health Service 3025 Non-US Insurance 3026 None 3027 Payer ID 3100 : Coronary Artery Disease 4000 Atrial Fibrillation/Flutter 4010 Dyslipidemia 4020 Diabetes Mellitus (Any) 4150 Hypertension 4030 Peripheral Vascular Disease 4230 Peripheral Arterial Disease 4090 PCI Bare Metal Stent Implant E002 PCI Drug Eluting Stent Implant E003 àdate 4022 àdate 4152 àdate 4032 àdate 4232 àdate 4092 Heart Failure 4040 à If Yes, New diagnosis 4050 (within 12 months) CAD - Unstable Angina 4080 CAD - Stable Angina 4060 à If Yes, New diagnosis 4070 (within 12 months) Ischemic Vascular Disease 4220 Chronic Kidney Disease 4240 Chronic Liver Disease 4250 Minor Hemorrhage E006 PatientID 2040 : Patient Deceased 2065 White 2070 Black/African American 2071 American Indian/Alaskan Native 2073 Asian 2072 à If Yes, Asian Indian 2080 Chinese 2081 Filipino 2082 Japanese 2083 Korean 2084 Vietnamese 2085 Other 2086 Native Hawaiian/Pacific Islander 2074 à If Yes, Native Hawaiian 2090 Guamanian or Chamorro 2091 Samoan 2092 Other Island 2093 Hispanic or Latino Ethnicity 2076 : à If Yes, Ethnicity Type: (Check all that apply) Mexican, Mexican-American, Chicano 2100 Puerto Rican 2101 Cuban 2102 Other Hispanic, Latino or Spanish Origin 2103 B. DIAGSES/CONDITIONS/CO-MORBIDITIES (CHECK ALL THAT APPLY) TE: INDICATE IF THE PATIENT HAS A HISTORY OF ANY OF THE FOLLOWING. PAD Acute Limb Ischemia 4100 PAD Claudication 4110 PAD Critical Limb Ischemia 4120 PAD Foot/Leg cellulitis 4130 PAD Lower Extremity Osteomyelitis (with or without limb ischemia) 4140 SPECIFY ALL EVENT(S) AND IF AVAILABLE, EVENT DATE(S) THAT OCCURRED. CAD Myocardial Infarction E001 PCI (Any) E029 àdate 4002 àdate 4012 àdate 4102 àdate 4112 àdate 4122 àdate 4132 àdate 4142 Intracranial Hemorrhage E007 (auto) Location Intra-articular (Atraumatic) E009 àdate 4042 àdate 4082 àdate 4062 àdate 4222 àdate 4242 àdate 4252 EVENT 5135 EVENT DATE(S) 5136 EVENT 5135 EVENT DATE(S) 5136 à If Yes, Etiology 4052 (Any) E032 à Date 2067 O Ischemic O Hypertensive O Valvular O Congenital O Idiopathic/dilated O Peripartum O Chemotherapy induced O Substance related O Tachycardia C. CARDIAC EVENTS TE: INDICATE IF THE PATIENT HAS A HISTORY OF ANY OF THE FOLLOWING. PCI Other (non-stent) Intervention E004 Coronary Artery Bypass Graft E017 Systemic Embolism E005 Location Intra-ocular E010 Location Intra-spinal E011 Hemorrhage (Any) E American College of Cardiology Foundation 27-Jun-2017 Page 1 of 6

2 MRN: Encounter Date: Practice ID: Location ID: C. CARDIAC EVENTS (CONT.) TE: INDICATE IF THE PATIENT HAS A HISTORY OF ANY OF THE FOLLOWING. SPECIFY ALL EVENT(S) AND IF AVAILABLE, EVENT DATE(S) THAT OCCURRED. EVENT 5135 EVENT DATE(S) 5136 EVENT 5135 EVENT DATE(S) 5136 Location Pericardial E012 Location Retroperitoneal/Abdominal E013 ICD Implant E025 Permanent Pacemaker E027 Carotid Endarterectomy (Any) E033 TIA E014 Carotid Endarterectomy Right E034 Stroke (Any) E030 Carotid Endarterectomy Left E035 Stroke Ischemic E015 Carotid Artery Stent (Any) E036 Stroke Hemorrhagic E016 Carotid Artery Stent Right E037 Cardiac Valve Surgery E018 Carotid Artery Stent Left E038 Heart Transplantation E019 PAD Peripheral Bypass E043 Cardioversion E021 PAD Peripheral Intervention E044 LVAD E022 Syncope E065 CRT E023 Left Bundle Branch Block E066 CRT-D E024 D. ENCOUNTER INFORMATION TE: COMPLETE ONLY IF ASSESSED DURING TODAY S ENCOUNTER. IF T ASSESSED, LEAVE BLANK. Height: O in 6000 O cm 6001 Blood Pressure 6010, 6011 : / mmhg Heart Rate 6015 : bpm Weight: O lbs 6020 O kg 6021 Patient unable to be weighed 6025 Tobacco Use 6030 : O Never O Current O Quit within past 12 months O Quit more than 12 months ago O Screening not performed for medical reasons à If Current or Quit within 12 months, Tobacco Type: (check all that apply) Cigarettes 6035 Cigars 6036 Pipe 6037 Smokeless 6038 à If Current or Quit within 12 months, Smoking Cessation Counseling Provided 6040 : QRS Duration (Non-Ventricular Paced Complex) 6028 : ms Patient asked, during any previous encounter in the past 24 months, about the use of Tobacco 6045 : Alcohol Use 6047 : ne O <1 drinks/wk O 2-7 drinks/wk O 8-14 drinks/wk O >= 15 drinks/wk Advance Care Plan OR Discussion of Advance Care Plan Documented 6050 : Not documented patient reason ANGINA SYMPTOMS AND ACTIVITY ASSESSMENT(S) TE: COMPLETE AT LEAST ONE TO MEET MEASURE. HF HF HF CAD CCS Class 6430 : Seattle Angina Questionnaire Completed 6435 NYHA Class 6130 : O I O II O III O IV Kansas City Cardiomyopathy Questionnaire Completed 6135 Other Tool/Method to Assess Heart Failure Activity Completed 6155 Dyspnea Present 6200 : Rales Present 6220 : angina O I O II O III O IV Stage of Heart Failure 6128 : O A O B O C O D Orthopnea Present 6210 : Peripheral Edema Present 6230 : Ascites Present 6250 : Hepatomegaly Present 6260 : Other Tool/Method to Assess Angina Symptoms and Activity Completed 6440 HEART FAILURE ACTIVITY ASSESSMENT(S) HEART FAILURE SYMPTOMS ASSESSMENT(S) HEART FAILURE PHYSICAL ASSESSMENT(S) à If Yes, score (0-100) 6136 TE: COMPLETE NYHA TO MEET MEASURE. TE: COMPLETE AT LEAST ONE TO MEET MEASURE. TE: COMPLETE AT LEAST ONE TO MEET MEASURE. S 3 Gallop Present 6240 : S 4 Gallop Present 6270 : Jugular Venous Distention Present 6275 : 2010 American College of Cardiology Foundation 27-Jun-2017 Page 2 of 6

3 MRN: Encounter Date: Practice ID: Location ID: PLAN OF CARE BMI CAD Body Mass Index Screen Performed 6900 àdate 6902 BMI Management Plan 6910 Cardiac Rehabilitation Referral or Plan for Qualifying Event/Diagnosis in past 12 months 6450 : Referral/Plan Documented Qualifying Event/Diagnosis O Patient Already Participating in Rehab (Note: Cardiac event/diagnoses includes Myocardial Infarction, Valve surgery, Heart Transplant, CABG, PCI or new Stable Angina diagnosis.) Referral for Consideration for Coronary Revascularization 6460 : Referral/Plan Medical Reason Referral/Plan System Reason Referral for Additional Evaluation/Treatment of Anginal Symptoms 6470 : Discussion of Lifestyle Modifications Documented 6100 : EF HF LVEF Assessed Date 6400 : LVEF 6410 : % LV Qualitative Assessment 6420 : (Note: If a LVEF range is documented, take the average, round up and refer to the LVEF Status ranges (right) to code.) O Hyperdynamic: > 70 rmal: O Mildly reduced: O Moderately reduced: O Severely reduced: 29 HF Education Completed/Documented: (Check all that apply) All of the following 6280 Weight Monitoring 6281 Diet (Sodium Restriction) 6282 Symptom Management 6283 Physical Activity 6284 Smoking Cessation 6285 Medication Instruction 6286 Prognosis/end-of-life Issues 6287 Minimizing or Avoiding use of NSAIDs 6288 Referral for visiting nurse or specific educational or management programs 6289 ICD Counseling 6300 : Patient Counseled Patient Not Counseled Counseling Medical Reason HF Plan of Care 6310 : ATRIAL FIBRILLATION/FLUTTER ASSESSMENT AND TREATMENT AFib/Flutter Duration 6500 : O First diagnosed O Paroxysmal O Persistent O Long-standing Persistent O Permanent AFib/Flutter Type 6510 : n-valvular O Valvular AFIB Afib/Flutter Etiology Transient/Reversible Cause 6520 (e.g., pneumonia, hyperthyroidism, pregnancy, post-surgery) INR Value 6530 : EP Study 6540 Atrial Ablation 6550 Atrial Fibrillation Recurrence 6560 àdate 6532 Atrial Fibrillation Symptom Frequency 6570 : (every) days àdate 6542 Atrial Fibrillation Symptom Duration 6580 : àdate 6552 O < 48 hours O >= 48 hours 7 days O >7 days 3 months O > 3 months àdate 6562 Rate Control Therapy 6590 Rhythm Control Therapy 6595 TE RISK FACTORS CHADS 2 Score 6600 : CHA 2 DS 2 -VASc Score 6610 : HAS-BLED Score 6620 : E. LABORATORY RESULTS TE: ENTER ALL LAB RESULTS AND/OR INDICATE THE LABS ORDERED DATES. Lipid Panel Obtained Date 7000 : Glucose timing 7060 : O Fasting O Random CAD Total Cholesterol 7010 : mg/dl High Density Lipoprotein (HDL) 7020 : mg/dl Low Density Lipoprotein (LDL) 7030 : mg/dl Direct Low Density Lipoprotein (DLDL) 7040 : mg/dl Diabetes Plasma Glucose Results 7070 : HbA1c 7080 : mg/dl % àdate 7072 àdate 7082 HgB 7510 : g/dl àdate 7512 RENAL HF Triglycerides 7050 : mg/dl Potassium 7110 : meq/l àdate 7112 Sodium 7115 : meq/l àdate 7117 B-type Natiuretic Peptide 7120 : pg/ml àdate 7122 N-terminal pro b-type Natiuretic Peptide 7125 : pg/ml àdate 7127 Estimated Glomerular Filtration Rate 7200 : ml/min àdate 7202 Creatinine Clearance 7220 : àdate 7222 Serum Creatinine 7230 : mg/dl àdate American College of Cardiology Foundation 27-Jun-2017 Page 3 of 6

4 MRN: Encounter Date: Practice ID: Location ID: F. S 9300 * DETES THAT THE (S) ARE REQUIRED FOR SPECIFIC PERFORMANCE MEASURES OR PQRS MEASURES + INDICATES A IS T YET BEEN APPROVED. DOSE STRENGTH 9301 PLEASE LEAVE BLANK IF THERE IS CLINICAL INDICATION FOR A TO BE PRESCRIBED, OR IF DOCUMENTATION EXISTS AS TO IF A WAS PRESCRIBED/CONTINUED. MEASURE 9302 (E.G. MG, ML) FREQUENCY 9303 CODE 9307 CODE SYSTEM MOST RECENT PRESCRIPTION DATE 9315 YES (PRESCRIBED) (MEDICAL (PATIENT (SYSTEM ANTIANGINAL Nitroglycerin Ranolazine ANTIARRYTHMIC ANTICOAGULANTS* Antiarrhythmic (Any) Amiodarone Dronedarone Apixaban Dabigatran Edoxaban Rivaroxaban Warfarin ANGIOTENSION RECEPTOR- NEPRILYSIN INHIBITOR Sacubitril/Valsartan ACE Inhibitor* ARB* Combination Antihypertensive ANTIHYPERTENSIVE CA CHANNEL BLOCKERS Calcium Channel Blocker (any) Dihydropyridine Non-Dihydropyridine Diuretic (Any) DIURETICS* Loop Diuretic Thiazide Diuretic Potassium Sparing Diuretic ANTIPLATELETS Aspirin Aspirin-dipyridamole (Aggrenox) P2Y12 INHIBITOR Clopidogrel Ticlopidine Prasugrel Ticagrelor THROMBIN RECEPTOR ANTAGONIST Vorapaxar (Zontivity) 1 PLEASE PROVIDE CODE SYSTEM VALUE: 1. GPI 2. MMSL 3. NDC 4. RXRM 5. SMED-CT 6. OTHER 2010 American College of Cardiology Foundation 27-Jun-2017 Page 4 of 6

5 MRN: Encounter Date: Practice ID: Location ID: F. S * DETES THAT THE (S) ARE REQUIRED FOR SPECIFIC PERFORMANCE MEASURES OR PQRS MEASURES + INDICATES A IS T YET BEEN APPROVED. Beta Blocker (Any) DOSE STRENGTH 9301 PLEASE LEAVE BLANK IF THERE IS CLINICAL INDICATION FOR A TO BE PRESCRIBED, OR IF DOCUMENTATION EXISTS AS TO IF A WAS PRESCRIBED/CONTINUED. MOST RECENT MEASURE PRESCRIPTION FREQUENCY CODE CODE YES 9303 CODE 9307 SYSTEM CODE YES SYSTEM 1 DATE (MEDICAL (MEDICAL (PATIENT (PATIENT (SYSTEM (E.G. (E.G. MG, MG, ML) ML) (PRESCRIBED) (PRESCRIBED) Atenolol BETA BLOCKER Metoprolol Tartrate Sustained release metoprolol succinate Bisoprolol Carvedilol Nebivolol HEART RATE LOWERING Ivabradine Insulin Metformin Pioglitazone Rosiglitazone GLUCOSE LOWERING SGLT-2 INHIBITORS DPP-4 INHIBITORS Canaglifozin Dapagliflozin Empagliflozin Sitagliptin Saxagliptin Linagliptin Alogliptin ALPHA- GLUOSIDASE Acarbose Miglitol Lipid Lowering Non-Statin Ezetimibe Lipid Lowering Statin (Any) Atorvastatin LIPID LOWERING STATIN Rosuvastatin Simvastatin Low Intensity Statin Moderate Intensity Statin High Intensity Statin PCKSK9 INHIBITORS Alirocumab Evolocumab 1 PLEASE PROVIDE CODE SYSTEM VALUE: 1. GPI 2. MMSL 3. NDC 4. RXRM 5. SMED-CT 6. OTHER 2010 American College of Cardiology Foundation 27-Jun-2017 Page 5 of 6

6 MRN: Encounter Date: Practice ID: Location ID: F. S * DETES THAT THE (S) ARE REQUIRED FOR SPECIFIC PERFORMANCE MEASURES OR PQRS MEASURES + INDICATES A IS T YET BEEN APPROVED. SMOKING CESSATION Bupropion Nicotine Replacement Therapy Varenicline DOSE STRENGTH 9301 PLEASE LEAVE BLANK IF THERE IS CLINICAL INDICATION FOR A TO BE PRESCRIBED, OR IF DOCUMENTATION EXISTS AS TO IF A WAS PRESCRIBED/CONTINUED. MOST RECENT MEASURE PRESCRIPTION FREQUENCY CODE CODE YES CODE CODE 9307 SYSTEM 1 YES SYSTEM 1 DATE (MEDICAL (MEDICAL (PATIENT (PATIENT (SYSTEM (E.G. (E.G. MG, MG, ML) ML) (PRESCRIBED) (PRESCRIBED) COMBINATION PILLS Hydralazine and Isosorbide Dinitrate OTHER Corticosteroids Digoxin (Any) NSAID Proton Pump Inhibitor SSRI 1 PLEASE PROVIDE CODE SYSTEM VALUE: 1. GPI 2. MMSL 3. NDC 4. RXRM 5. SMED-CT 6. OTHER G. HOSPITALIZATIONS Hospital Admission Date 9500 : à If Admitted, Primary Reason 9505 : Coding Standard 9510 : O ICD-9 O ICD-10 Discharge Date 9502 : Secondary Diagnosis 9507 : 2010 American College of Cardiology Foundation 27-Jun-2017 Page 6 of 6