Arkansas Health Care Payment Improvement Initiative CABG Algorithm Summary

Transcription

1 Arkansas Health Care Payment Improvement Initiative CABG Algorithm Summary

2 CABG Algorithm Summary v1.6 Page 2 of 25 Triggers PAP assignment Exclusions Episode time window An episode is triggered when a patient shows a claim with a HCPCS procedure code for coronary artery bypass graft(s) (CABG). For procedure, please see dataset. The Principal Accountable Provider (PAP) for a CABG episode is the provider performing the procedure, must be enrolled in an Arkansas Blue Plan provider network and reflect any of the following specialty designations: General Surgery, Cardiology, Internal Medicine, Neurosurgery, Diagnostic Radiology, Thoracic Surgery, Vascular Surgery, Cardiac Surgery, Emergency Medicine, Interventional Radiology Episodes meeting one or more of the following criteria will be excluded: A. The patient has claims or enrollment records that indicate coordination of benefits with another payer not associated with the Arkansas Blue Plans within the duration of the episode B. The patient does not have continuous coverage with at least one Arkansas Blue Plan throughout the entire episode C. The patient has a coordination of benefits with another payer D. The overall episode cost for the patient exceeds the outlier criteria. Currently, the outlier threshold is set at three standard deviations above the average episode cost for all patients otherwise included in the reporting period for all PAPs. E. The patient expired or was discharged against medical advice F. Patient age on date of trigger procedure is less than 18 or greater than 65 G. Trigger procedures that do not have a corresponding facility claim H. The patient had more than one valve procedure performed I. The episode window overlaps with another episode J. The CABG procedure was a converted from a PCI K. Provider contract with Arkansas Blue Cross terminated prior to episode report publication L. The patient s claims indicate any of the following co-morbidities within 365 days prior to the procedure and the end of the episode: Abortion complications, Amnios, Arteritis NOS, Bladder cancer, Bone cancer, Brain cancer, Breast cancer, Bronchial/lung cancer, Cervix cancer, Colon cancer, Esophageal cancer, ESRD (end-stage renal disease), Female genital cancer, Fetal disturbances, Forceps or vacuum extractor delivery, GI/Perit Cancer, Head/Neck cancer, HIV, Hodgkin's lymphoma, Kidney/renal cancer, Leukemias, Liver cancer, Maintenance chemical, Male genital cancer, Malignant neoplasm, Malposition, Multiple myeloma, Neoplasm unspecified, Non- Hodgkin's lymphoma, Other perinatal diagnosis, Other primary cancer, Other respiratory cancer, Ovarian cancer, Pancreas cancer, Episode overlaps with another episode, Pelvic obstruction, Perinatal jaundice, Poison nonmedical, Polyarteritis nodosa and allied conditions, Prostate cancer, Rectum/anus cancer, Respiratory distress, Skin melanoma, Spontaneous abortion, Stomach cancer, Suicide and intentional self-inflicted injury, Testicle cancer, Thyroid cancer, Transplant, Umbilical cord complications, Urinary organ cancer, Uterus cancer, Louse-borne typhus, Dialysis, Complications from organ transplants M. Patient is an Exchange member N. Patient is an Access Only member O. Non-par self-insured groups: ABB/Baldor, Greenbay Packaging, Hytrol, Nabholz, Navistar, Nucor, Replacement Parts, Riceland, Southern Steel and Wire A CABG episode begins on the day of the trigger procedure (even if patient is admitted before the day of the procedure) and ends 30 days after the trigger date.

3 CABG Algorithm Summary v1.6 Page 3 of 25 included The following services are included if incurred within the episode: A. All claims for inpatient admissions. with a DRG on the CMS list of exclusions for cardiac surgery will not be included in the episode. B. All claims in the following places of service that show a CABG related ICD-9-CM diagnosis: inpatient professional, emergency room, skilled nursing facility, comprehensive inpatient rehab facility C. All claims for select CPT/HCPCS procedures in the following places of service: office, outpatient facility, ambulance Quality measures Utilization Adjustments Trigger After all above criteria are applied, remaining claims will be excluded for select CPT/HCPCS procedures, regardless of the place of service in which it is billed. Quality measures to pass (payment related): A. There are currently no measures linked to Gain Sharing. Quality measures to track (not payment related): A. Average length of pre-procedure inpatient stay B. Percentage of patients admitted on day of procedure C. Percentage of patients for which an internal mammary artery is used There are no utilization measures at this time The total reimbursements attributed to the PAP will be adjusted based on complications that resulted in variations in treatment using a multiplier determined by regression. Over time, risk factors may be added or subtracted based on new research and/or empirical evidence. with following are considered when triggering an episode: HCPCS: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, S2205, S2206, S2207, S2208, S2209

4 CABG Algorithm Summary v1.6 Page 4 of 25 Exclusion Patients who have co-morbid condition(s) indicated by the following will be excluded: ICD-9-CM Diagnosis: 189.3, 189.4, 189.8, 189.9, 190.0, 190.1, 190.2, 190.3, 190.4, 190.5, 190.6, 190.7, 190.8, 190.9, 191.0, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9, 192.0, 192.1, 192.2, 192.3, 192.8, 192.9, 193, 194.0, 194.1, 194.3, 194.4, 194.5, 194.6, 194.8, 194.9, 195.0, 195.1, 195.2, 195.3, 195.4, 195.5, 195.8, 196.0, 196.1, 196.2, 196.3, 196.5, 196.6, 196.8, 196.9, 197.0, 197.1, 197.2, 197.3, 197.4, 197.5, 197.6, 197.7, 197.8, 198.0, 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, , , , 199.0, 199.1, 199.2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Patients who have co-morbid condition(s) indicated by the following will be excluded: ICD-9-CM Diagnosis: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 203.0, , , , 203.1, , , , 203.8, , , , 204.0, , , , 204.1, , , , 204.2, , , , 204.8, , , , 204.9, , , , 205.0, , , , 205.1, , , , 205.2, , , , 205.3, ,205.31, , 205.8, , , , 205.9, , , , 206.0, , , , 206.1, , , , , , , 206.8, , , , 206.9, , , , 207.0, , , , 207.1, , , , 207.2, , , , 207.8, , , , 208.0, , , , 208.1, , , , 208.2, , , , 208.8, , , , 208.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 230.0, 230.1, 230.2, 230.3, 230.4, 230.5, 230.6, 230.7, 230.8, 230.9, 231.0, 231.1, 231.2, 231.8, 231.9, 233.0, 233.1, 233.2, 233.3, , , , , 233.4, 233.5, 233.6, 233.7, 233.9, 234.0, 234.8, 234.9, 235.0, 235.1, 235.2, 235.3, 235.4, 235.5, 235.6, 235.7, 235.8, 235.9, 236.0, 236.1, 236.2, 236.3, 236.4, 236.5, 236.6, 236.7, , , , 237.0, 237.1, 237.2, 237.3, 237.4, 237.5, 237.6, 237.7, ,237.71, , , , 237.9, 238.0, 238.1, 238.2, 238.3, 238.4, 238.5, 238.6, 238.7, , , , , , , , , 238.8, 238.9, 239.0, 239.1, 239.2, 239.3, 239.4, 239.5, 239.6, 239.7, 239.8, , , 239.9, , , , , 446.0, 446.1, , , , 446.3, 446.4, 446.5, 446.6, 446.7, 447.6, , 585.5, 585.6, , , , , , , ,

5 CABG Algorithm Summary v1.6 Page 5 of 25 Exclusion Codes (Continued) ICD-9-CM Diagnosis: , , , , , , , , , , , , , , , , , , , , , , , , 639.0, 639.1, 639.2, 639.3, 639.4, 639.5, 639.6, 639.8, 639.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Patients who have co-morbid condition(s) indicated by the following will be excluded: ICD-9-CM Diagnosis: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 760.0, 760.1, 760.2, 760.3, 760.4, 760.5, 760.6, , , , , , , , , , , 760.8, 760.9, 761.0, 761.1, 761.2, 761.3, 761.4, 761.5, 761.6, 761.7, 761.8, 761.9, 762.0, 762.1, 762.2, 762.3, 762.4, 762.5, 762.6, 762.7, 762.8, 762.9, 763.0, 763.1, 763.2, 763.3, 763.4, 763.5, 763.6, 763.7, 763.8, , , , , , 763.9, 766.0, 766.1, 766.2, , , 769, 770.0, 770.1, , , , , , , , , , 770.2, 770.3, 770.4, 770.5, 770.6, 770.7, 770.8, , , , , , , , , 770.9, 771.0, 771.1, 771.2, 771.3, 771.4, 771.5, 771.6, 771.7, 771.8, , , , 772.0, 772.1, , , , , , 772.2, 772.3, 772.4, 772.5, 772.6, 772.8, 772.9, 773.0, 773.1, 773.2, 773.3, 773.4, 773.5, 774.0, 774.1, 774.2, , , , 774.4, 774.5, 774.6, 774.7, 775.0, 775.1, 775.2, 775.3, 775.4, 775.5, 775.6, 775.7, 775.8, , , 775.9, 776.0, 776.1, 776.2, 776.3, 776.4, 776.5, 776.6, 776.7, 776.8, 776.9, 777.1, 777.2, 777.3, 777.4, 777.5, , , , , 777.6, 777.8, 777.9, 778.0, 778.1, 778.2, 778.3, 778.4, 778.5, 778.6, 778.7, 778.8, 778.9, 779.0, 779.1, 779.2, 779.3, , , , , 779.4, 779.6, 779.7, 779.8, , , , , , , 779.9, , , , 789.7, 792.3, 795.0, ,795.1, , ,795.12, , , , , 795.8, , , , , , , 909.1, 980.1, 980.2, 980.3, 980.8, 980.9, 981, 982.0, 982.1, 982.2, 982.3, 982.4, 982.8, 983.0, 983.1, 983.2, 983.9, 984.0, 984.1, 984.8, 984.9, 985.0, 985.1, 985.2, 985.3, 985.4, 985.5, 985.6, 985.8, 985.9, 986, 987.0, 987.1, 987.2, 987.3, 987.4, 987.5, 987.6, 987.7, 987.8, 987.9, 988.0, 988.1, 988.2, 988.8, 988.9, 989.0, 989.1, 989.2, 989.3, 989.4, 989.5, 989.6, 989.7, 989.8, , , , , , 989.9, 996.8, , , , , , , , , , , E950, E950.0, E950.1, E950.2, E950.3, E950.4, E950.5, E950.6, E950.7, E950.8, E950.9, E951, E951.0, E951.1, E951.8, E952, E952.0, E952.1, E952.8, E952.9, E953, E953.0, E953.1, E953.8, E953.9, E954, E955, E955.0, E955.1, E955.2, E955.3, E955.4, E955.5, E955.6, E955.7, E955.9, E956, E957, E957.0, E957.1, E957.2, E957.9, E958, E958.0, E958.1, E958.2, E958.3, E958.4, E958.5, E958.6, E958.7, E958.8, E958.9,

6 CABG Algorithm Summary v1.6 Page 6 of 25 Exclusion Codes (Continued) ICD-9-CM Diagnosis: V08, V10.0, V10.00, V10.01, V10.02, V10.03, V10.04, V10.05, V10.06, V10.07, V10.09, V10.11, V10.12, V10.20, V10.21, V10.22, V10.29, V10.3, V10.40, V10.41, V10.42, V10.43, V10.44, V10.45, V10.46, V10.47, V10.48, V10.49, V10.50, V10.51, V10.52, V10.53, V10.59, V10.60, V10.61, V10.62, V10.63, V10.69, V10.71, V10.72, V10.79, V10.81, V10.82, V10.84, V10.85, V10.86, V10.87, V10.88, V10.89, V10.9, V10.90, V10.91, V13.7, V42.0, V42.1, V42.5, V42.7 Patients who have co-morbid condition(s) indicated by the following will be excluded: ICD-9-CM Diagnosis: V45.1, V45.11, V45.12, V50.2, V56, V56.0, V56.1, V56.2, V56.3, V56.31, V56.32, V56.8, V58.0, V58.1, V58.11, V58.12, V62.84, V66.1, V66.2, V67.1, V67.2, V71.1 ICD-9 Procedure: 00.40, 00.41, 00.42, 00.43, 00.44, 00.66, 36.01, 36.02, 36.04, 36.05, HCPCS Procedure: 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92942, 92943, 92944, 92973, 92974, 92975, 92980, 92981, 92982, 92984, 92995, 92996, 99.10, G0290, G0291 included Please see the final pages of this document for a list of the corresponding ICD-10 In addition to all inpatient facility claims, claims with one of the following are included when performed in an inpatient professional, emergency room, skilled nursing facility, or comprehensive inpatient rehab facility: HCPCS Procedure: 10180, 12020, 12021, 13160, 33202, 33203, 33206, 33207, 33208, 33209, 33210, 33211, 33212, 33213, 33214, 33215, 33216, 33217, 33218, 33219, 33220, 33221, 33222, 33223, 33224, 33225, 33226, 33227, 33228, 33229, 33230, 33231, 33233, 33234, 33235, 33236, 33237, 33238, 33239, 33240, 33241, 33242, 33243, 33244, 33249, 33250, 33251, 33252, 33253, 33254, 33255, 33256, 33257, 33258, 33259, 33260, 33261, 33262, 33263, 33264, 33320, 33321, 33322, 33330, 33332, 33335, 33400, 33401, 33403, 33405, 33406, 33410, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33422, 33425, 33426, 33427, 33430, 33460, 33463, 33464, 33465, 33472, 33474, 33475, 33476, 33478, 33496, 33510, 33511, 33512, 33513, 33514, 33515, 33516, 33517, 33518, 33519, 33520, 33521, 33522, 33523, 33530, 33533, 33534, 33535, 33536, 33542, 33545, 33548, 33572, 33860, 33863, 33864, 33870, 33875, 33877, 33960, 33961, 33967, 33968, 33969, 33970, 33971, 33972, 33973, 33974, 33975, 33976, 33977, 33978, 33979, 33980, 34001, 35301, 35390, 35701, 35820, 35875, 35876, 71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75600, 75605, 75625, 75630, 75635, 75658, 75705, 75710, 75716, 75726, 75731, 75733, 75736, 75741, 75743, 75746, 75756, 75774, 75791, 92960, 92970, 92971, 92973, 92974, 92975, 92980, 92981, 92982, 92983, 92984, 92995, 92996, 93000, 93005, 93010, 93015, 93016, 93017, 93018, 93024, 93025, 93040, 93041, 93042, 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 93278, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93501, 93508, 93510, 93511, 93514, 93524, 93526, 93527, 93528, 93529, 93539, 93540, 93541, 93542, 93543, 93544, 93545, 93555, 93556, 93600, 93602, 93603, 93609, 93610, 93612, 93613, 93615, 93616, 93618, 93619, 93620, 93621, 93622, 93623, 93624, 93631, 93640, 93641, 93642, 93650, 93651, 93652, 93653, 93654, 93655, 93656, 93657, 93797, 93798, G0269, S2205, S2206, S2207, S2208, S2209 ICD-9 Procedure: 00.40, 00.41, 00.42, 00.43, 00.44, 00.45, 00.46, 00.47, 00.48, 00.50, 00.51, 00.52, 00.53, 00.54, 00.66, 35.10, 35.11, , 36.14, 36.15, 36.16, 36.17, 36.19, 36.2, 36822, 37.0, 37.21, 37.22, 37.23, 37.26, 37.27, 37.29, 37.32, 37.33, 37.34, 37.35, 37.36, 37.60, 37.61, 37.62, 37.63, 37.64, 37.65, 37.66, 37.67, 37.68, 37.70, 37.71, 37.72, 37.73, 37.74, 37.75, 37.76, 37.77, 37.78, 37.79, 37.80, 37.81, 37.82, 37.83, 37.85, 37.86, 37.87, 37.89, 37.94, 37.95, 37.96, 37.97, 37.98, 37.99, 38.05, 38.12, 38.35, 38.45, 39.54, 39.61, 39.62, 39.63, 39.64, 39.65, 39.66, 49.00, 54.61, 54.62, 84.49, 86.04, 86.22, 86.28, 86.59, 87.44, 88.4, 88.40, 88.41, 88.42, 88.43, 88.44, 88.45, 88.46, 88.47, 88.48,

7 CABG Algorithm Summary v1.6 Page 7 of 25 included ICD-9 Procedure: 88.49, 88.5, 88.50, 88.51, 88.52, 88.53, 88.54, 88.55, 88.56, 88.57, 88.58, 88.59, 88.72, 88.92, 89.41, 89.42, 89.43, 89.44, 89.45, 89.46, 89.47, 89.48, 89.49, 89.50, 89.51, 89.52, 89.53, 89.54, 89.55, 89.56, 89.57, 89.58, 89.59, 89.60, 89.61, 89.62, 89.63, 89.64, 89.65, 89.66, 89.67, 89.68, 89.69, 92.05, 93.36, 96.59, 99.10, 99.6, 99.61, 99.62, 99.64, 99.69, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 251.0, 251.1, 251.2, , , , , 278.1, 293.1, , , , , , , , , , 394.0, 394.1, 394.2, 394.9, 395.0, 395.1, 395.2, 395.9, 396.0, 396.1, 396.2, 396.3, 396.8, 396.9, 397.0, 397.1, 397.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 411.0, 411.1, , , , , , , , , , 412, 412., 413.0, 413.1, 413.9, , , , , , , , , , , , , , , , , , , 414.2, 414.3, 414.4, 414.8, 414.9, , , 421.0, 421.1, 421.9, 423.3, 424.0, 424.1, 424.2, 424.3, , , , , , , , , , 425.0, 425.2, 425.3, 425.4, 425.5, 425.7, 425.8, 425.9, 426.0, , , , , 426.2, 426.3, 426.4, , , , , , 426.6, 426.7, , , , , , , , , , 426.9, 427.0, 427.2, , , , , , , , 427.9, 428.0, 428.1, , , , , , , , , , , , , 428.9, 429.0, 429.1, 429.2, 429.3, 429.4, 429.5, 429.6, , , , , , , , , , , , 429.9, 441.2, , , , , 512.1, 513.1, 514, 514., 519.2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 998.2, 998.3, , , 998.4, , , 998.7, , 999.1, , 999.6, E867.2, E870.0, E884.2, E884.3, E884.4, E884.5, E884.6, V09.0 In addition to all inpatient facility claims, claims with one of the following are included when performed in an inpatient professional, emergency room, skilled nursing facility, or comprehensive inpatient rehab facility: NDC: There are at least 124,000 NDC. Can provide upon request. Quality Utilization Please see the final pages of this document for a list of the corresponding ICD-10 Inpatient facility claims with the following ICD-9 procedure will determine whether an internal mammary artery is used ICD-9 Procedure: 36.15, Please see the final pages of this document for a list of the corresponding ICD-10 No utilization.

8 CABG Algorithm Summary v1.6 Page 8 of 25 Exclusion Patients who have co-morbid condition(s) indicated by the following will be excluded: ICD-10-CM Diagnosis: A4851, B20, B9735, A750, C000, C001, C003, C004, C005, C006, C008, C002, C009, C01, C020, C021, C022, C023, C024, C028, C029, C07, C080, C081, C089, C030, C031, C039, C040, C041, C048, C049, C060, C061, C050, C051, C052, C058, C059, C062, C0680, C0689, C069, C098, C099, C090, C091, C100, C101, C102, C103, C104, C108, C109, C110, C111, C112, C113, C118, C119, C130, C12, C131, C132, C138, C139, C140, C142, C148, C153, C154, C155, C158, C159, C160, C164, C163, C161, C162, C165, C166, C168, C169, C170, C171, C172, C173, C178, C179, C183, C184, C186, C187, C180, C181, C182, C185, C188, C189, C19, C20, C211, C210, C212, C218, C220, C222, C223, C224, C227, C228, C221, C229, C23, C240, C241, C248, C249, C250, C251, C252, C253, C254, C257, C258, C259, C480, C451, C481, C488, C482, C260, C261, C269, C300, C301, C310, C311, C312, C313, C318, C319, C320, C321, C322, C323, C328, C329, C33, C3400, C3401, C3402, C3410, C3411, C3412, C342, C3430, C3431, C3432, C3480, C3481, C3482, C3490, C3491, C3492, C384, C450, C37, C380, C452, C381, C382, C388, C383, C390, C399, C410, C411, C412, C413, C4000, C4001, C4002, C4010, C4011, C4012, C414, C4020, C4021, C4022, C4030, C4031, C4032, C4080, C4081, C4082, C4090, C4091, C4092, C419, C470, C490, C4710, C4711, C4712, C4910, C4911, C4912, C4720, C4721, C4722, C4920, C4921, C4922, C473, C493, C474, C494, C475, C495, C476, C496, C478, C498, C479, C499, C430, D030, C4310, C4311, C4312, D0310, D0311, D0312, C4320, C4321, C4322, D0320, D0321, D0322, C4330, C4331, C4339, D0330, D0339, C434, D034, C4351, C4352, C4359, D0351, D0352, D0359, C4360, C4361, C4362, D0360, D0361, D0362, C4370, C4371, C4372, D0370, D0371, D0372, C438, D038, C439, D039, C50011, C50012, C50019, C50111, C50112, C50119, C50211, C50212, C50219, C50311, C50312, C50319, C50411, C50412, C50419, C50511, C50512, C50519, C50611, C50612, C50619, C50811, C50812, C50819, C50911, C50912, C50919, C50021, C50022, C50029, C50121, C50122, C50129, C50221, C50222, C50229, C50321, C50322, C50329, C50421, C50422, C50429, C50521, C50522, C50529, C50621, C50622, C50629, C50821, C50822, C50829, C50921, C50922, C50929, C460, C461, C462, C464, C4650, C4651, C4652, C463, C467, C469, C55, C530, C531, C538, C539, C58, C541, C542, C543, C549, C540, C548, C561, C562, C569, C5700, C5701, C5702, C5710, C5711, C5712, C573, C5720, C5721, C5722, C574, C574, C52, C510, C511, C512, C519, C518, C577, C578, C579, C61, C6200, C6201, C6202, C6210, C6211, C6212, C6290, C6291, C6292, C600, C601, C602, C609, C6300, C6301, C6302, C6310, C6311, C6312, C632, C608, C637, C638, C639, C670, C671, C672, C673, C674, C675, C676, C677, C678, C679, C641, C642, C649, C651, C652, C659, C661, C662, C669, C680, C681, C688, C689, C6940, C6941, C6942, C6960, C6961, C6962, C6900, C6901, C6902, C6910, C6911, C6912, C6920, C6921, C6922, C6930, C6931, C6932, C6950, C6951, C6952, C6980, C6981, C6982, C6990, C6991, C6992, C710, C711, C712, C713, C714, C715, C716, C717, C718, C719, C7220, C7221, C7222, C7230, C7231, C7232, C7240, C7241, C7242, C7250, C7259, C700, C709, C720, C721, C701, C729, C73, C7400, C7401, C7402, C7410, C7411, C7412, C7490, C7491, C7492, C750, C751, C752, C753, C754, C755, C758, C759, C760, C761, C762, C763, C7640, C7641, C7642, C7650, C7651, C7652, C457, C768, C770, C771, C772, C773, C774, C775, C778, C779, C7800, C7801, C7802, C781, C782, C7830, C7839, C784, C785, C786, C787, C7880, C7889, C7900, C7901, C7902, C7910, C7911, C7919, C792, C7931, C7932, C7940, C7949, C7951, C7952, C7960, C7961, C7962, C7970, C7971, C7972, C7981, C7982, C7989, C799, C800, C459, C801, C802, C8330, C8339, C8331, C8332, C8333, C8334, C8335, C8336, C8337, C8338, C8350, C8359, C8351, C8352, C8353, C8354, C8355, C8356, C8357, C8358, C8370, C8379, C8371, C8372, C8373, C8374, C8375, C8376, C8377, C8378, C8380, C8389, C884, C8382, C8383, C8387, C8310, C8319, C8311, C8312, C8313, C8314, C8315, C8316, C8317, C8318, C8381, C8460, C8469, C8470, C8479, C8461, C8471, C8462, C8472, C8463, C8473, C8464, C8474, C8465, C8475, C8466, C8476, C8467, C8477, C8468, C8478, C8300, C8309, C8390, C8399, C865, C866, C8301, C8391, C8302, C8392, C8303, C8393, C8304, C8384, C8394, C8305, C8385, C8395, C8306, C8386, C8396, C8307, C8397, C8308, C8388, C8398, C8171, C8173, C8174, C8177, C8170, C8179, C8172, C8175, C8176, C8178, C8100, C8109, C8140, C8149, C8101, C8141, C8102, C8142, C8103, C8143, C8104, C8144, C8105, C8145, C8106, C8146, C8107, C8147, C8108, C8148, C8110, C8119, C8111, C8112, C8113, C8114, C8115, C8116, C8117, C8118, C8120, C8129, C8121, C8122, C8123, C8124, C8125, C8126, C8127, C8128, C8130, C8139, C8131, C8132, C8133, C8134, C8135, C8136,

9 CABG Algorithm Summary v1.6 Page 9 of 25 Exclusion ICD-10-CM Diagnosis : C8137, C8138, C8190, C8199, C8191, C8192, C8193, C8194, C8195, C8196, C8197, C8198, C8200, C8209, C8210, C8219, C8220, C8229, C8230, C8239, C8240, C8249, C8260, C8269, C8280, C8289, C8290, C8299, C8201, C8211, C8221, C8231, C8241, C8261, C8281, C8291, C8202, C8212, C8222, C8232, C8242, C8262, C8282, C8292, C8203, C8213, C8223, C8233, C8243, C8263, C8283, C8293, C8204, C8214, C8224, C8234, C8244, C8264, C8284, C8294, C8205, C8215, C8225, C8235, C8245, C8265, C8285, C8295, C8206, C8216, C8226, C8236, C8246, C8266, C8286, C8296, C8207, C8217, C8227, C8237, C8247, C8267, C8287, C8297, C8208, C8218, C8228, C8238, C8248, C8268, C8288, C8298, C8400, C8409, C8401, C8402, C8403, C8404, C8405, C8406, C8407, C8408, C8410, C8419, C8411, C8412, C8413, C8414, C8415, C8416, C8417, C8418, C96A, C9140, C9141, C9142, C960, C962, C8440, C8449, C8441, C8442, C8443, C8444, C8445, C8446, C8447, C8448, C8250, C8259, C8490, C8499, C84A0, C84A9, C84Z0, C84Z9, C8510, C8519, C8520, C8529, C8580, C8589, C8590, C8599, C864, C8251, C8491, C84A1, C84Z1, C8511, C8521, C8581, C8591, C860, C8252, C8492, C84A2, C84Z2, C8512, C8522, C8582, C8592, C8253, C8493, C84A3, C84Z3, C8513, C8523, C8583, C8593, C862, C863, C8254, C8494, C84A4, C84Z4, C8514, C8524, C8584, C8594, C8255, C8495, C84A5, C84Z5, C8515, C8525, C8585, C8595, C8256, C8496, C84A6, C84Z6, C8516, C8526, C8586, C8596, C8257, C8497, C84A7, C84Z7, C8517, C8527, C8587, C8597, C861, C8258, C8498, C84A8, C84Z8, C8518, C8528, C8588, C8598, C964, C969, C96Z, C9000, C9001, C9002, C9010, C9011, C9012, C882, C883, C889, C9020, C9030, C9021, C9031, C9022, C9032, C9100, C9101, C9102, C9110, C9111, C9112, C9130, C9150, C9160, C91A0, C91Z0, C9131, C9151, C9161, C91A1, C91Z1, C9132, C9152, C9162, C91A2, C91Z2, C9190, C9191, C9192, C9200, C9240, C9250, C9260, C92A0, C9201, C9241, C9251, C9261, C92A1, C9202, C9242, C9252, C9262, C92A2, C9210, C9211, C9212, C9220, C9221, C9222, C9230, C9231, C9232, C92Z0, C92Z1, C92Z2, C9290, C9291, C9292, C9300, C9301, C9302, C9310, C9311, C9312, C9392, C9330, C93Z0, C9331, C93Z1, C9332, C93Z2, C9390, C9391, C9400, C9401, C9402, C9420, C9421, C9422, C9430, C9480, C9431, C9481, C9432, C9482, C9500, C9501, C9502, C9510, C9511, C9512, C9590, C9591, C9592, C7A019, C7A010, C7A011, C7A012, C7A029, C7A020, C7A021, C7A022, C7A023, C7A024, C7A025, C7A026, C7A00, C7A090, C7A091, C7A092, C7A093, C7A094, C7A095, C7A096, C7A098, C7A1, C7A8, C7B00, C7B01, C7B02, C7B03, C7B04, C7B1, C7B09, C7B8, D0000, D0001, D0002, D0003, D0004, D0005, D0006, D0007, D0008, D001, D002, D010, D011, D012, D013, D0140, D0149, D015, D017, D019, D020, D021, D0220, D0221, D0222, D023, D024, D0500, D0501, D0502, D0510, D0511, D0512, D0580, D0581, D0582, D0590, D0591, D0592, D060, D061, D067, D069, D070, D0730, D072, D071, D0739, D075, D074, D0760, D0761, D0769, D090, D0910, D0919, D0920, D0921, D0922, D093, D098, D099, D37030, D37031, D37032, D37039, D3701, D3702, D3704, D3705, D3709, D371, D372, D373, D374, D375, D376, D483, D484, D378, D379, D380, D381, D382, D383, D384, D385, D386, D390, D392, D3910, D3911, D3912, D398, D399, D4010, D4011, D4012, D400, D408, D409, D414, D419, D4100, D4101, D4102, D4110, D4111, D4112, D4120, D4121, D4122, D413, D418, D443, D444, D445, D4410, D4411, D4412, D446, D447, D440, D442, D449, D430, D431, D432, D434, D420, D421, D429, Q8500, Q8501, Q8502, Q8503, Q8509, D433, D438, D439, D480, D481, D482, D485, D4860, D4861, D4862, D45, D470, D473, D460, D461, D4620, D4621, D464, D46A, D46B, D4622, D46C, D469, D46Z, D47Z1, C888, C9440, C9441, C9442, C946, D471, D479, D47Z9, D487, D489, D490, D491, D492, D493, D494, D495, D496, D497, D4981, D4989, D499, E3122, E3123, D831, D806, D808, D809, M300, M302, M308, M317, M303, M310, M312, M301, M3130, M3131, M315, M316, M311, M314, I776, J910, N185, N186, O030, O0337, O035, O0387, O031, O036, O0334, O0384, O0332, O0382, O0333, O0383, O0331, O0381, O037, O032, O0335, O0336, O0338, O0339, O0385, O0386, O0388, O0389, O0330, O0380, O034, O039, A34, O080, O0882, O081, O086, O084, O085, O083, O082, O087, O0881, O0883, O0889, O089, O320XX0, O320XX1, O320XX2, O320XX3, O320XX4, O320XX5, O320XX9, O321XX0, O321XX1, O321XX2, O321XX3, O321XX4, O321XX5, O321XX9, O641XX0, O641XX1, O641XX2, O641XX3, O641XX4, O641XX5, O641XX9, O322XX0, O322XX1, O322XX2, O322XX3, O322XX4, O322XX5, O322XX9, O323XX0, O323XX1, O323XX2, O323XX3, O323XX4, O323XX5, O323XX9, O642XX0, O642XX1, O642XX2, O642XX3, O642XX4, O642XX5, O642XX9, O643XX0, O643XX1, O643XX2, O643XX3, O643XX4, O643XX5, O643XX9, O324XX0, O324XX1, O324XX2, O324XX3, O324XX4, O324XX5, O324XX9, O329XX0, O329XX1, O329XX2, O329XX3, O329XX4,

10 CABG Algorithm Summary v1.6 Page 10 of 25 Exclusion ICD-10-CM Diagnosis : O329XX5, O329XX9, O666, O326XX0, O326XX1, O326XX2, O326XX3, O326XX4, O326XX5, O326XX9, O328XX0, O328XX1, O328XX2, O328XX3, O328XX4, O328XX5, O328XX9, O644XX0, O644XX1, O644XX2, O644XX3, O644XX4, O644XX5, O644XX9, O645XX0, O645XX1, O645XX2, O645XX3, O645XX4, O645XX5, O645XX9, O648XX0, O648XX1, O648XX2, O648XX3, O648XX4, O648XX5, O648XX9, O649XX0, O649XX1, O649XX2, O649XX3, O649XX4, O649XX5, O649XX9, O650, O331, O651, O332, O652, O333XX0, O333XX1, O333XX2, O333XX3, O333XX4, O333XX5, O333XX9, O653, O334XX0, O334XX1, O334XX2, O334XX3, O334XX4, O334XX5, O334XX9, O654, O335XX0, O335XX1, O335XX2, O335XX3, O335XX4, O335XX5, O335XX9, O662, O336XX0, O336XX1, O336XX2, O336XX3, O336XX4, O336XX5, O336XX9, O337, O338, O339, O409XX0, O409XX1, O409XX2, O409XX3, O409XX4, O409XX5, O409XX9, O401XX0, O401XX1, O401XX2, O401XX3, O401XX4, O401XX5, O401XX9, O402XX0, O402XX1, O402XX2, O402XX3, O402XX4, O402XX5, O402XX9, O403XX0, O403XX1, O403XX2, O403XX3, O403XX4, O403XX5, O403XX9, O4100X0, O4100X1, O4100X2, O4100X3, O4100X4, O4100X5, O4100X9, O4101X0, O4101X1, O4101X2, O4101X3, O4101X4, O4101X5, O4101X9, O4102X0, O4102X1, O4102X2, O4102X3, O4102X4, O4102X5, O4102X9, O4103X0, O4103X1, O4103X2, O4103X3, O4103X4, O4103X5, O4103X9, O4200, O42019, O4290, O42919, O4200, O42011, O42012, O42013, O4202, O42911, O42912, O42913, O4292, O42119, O4210, O42111, O42112, O42113, O4212, O755, O411090, O411091, O411092, O411093, O411094, O411095, O411099, O411290, O411291, O411292, O411293, O411294, O411295, O411299, O411490, O411491, O411492, O411493, O411494, O411495, O411499, O411010, O411011, O411012, O411013, O411014, O411015, O411019, O411020, O411021, O411022, O411023, O411024, O411025, O411029, O411030, O411031, O411032, O411033, O411034, O411035, O411039, O411210, O411211, O411212, O411213, O411214, O411215, O411219, O411220, O411221, O411222, O411223, O411224, O411225, O411229, O411230, O411231, O411232, O411233, O411234, O411235, O411239, O411410, O411411, O411412, O411413, O411414, O411415, O411419, O411420, O411421, O411422, O411423, O411424, O411425, O411429, O411430, O411431, O411432, O411433, O411434, O411435, O411439, O418X90, O418X91, O418X92, O418X93, O418X94, O418X95, O418X99, O418X10, O418X11, O418X12, O418X13, O418X14, O418X15, O418X19, O418X20, O418X21, O418X22, O418X23, O418X24, O418X25, O418X29, O418X30, O418X31, O418X32, O418X33, O418X34, O418X35, O418X39, O4190X0, O4190X1, O4190X2, O4190X3, O4190X4, O4190X5, O4190X9, O4191X0, O4191X1, O4191X2, O4191X3, O4191X4, O4191X5, O4191X9, O4192X0, O4192X1, O4192X2, O4192X3, O4192X4, O4192X5, O4192X9, O4193X0, O4193X1, O4193X2, O4193X3, O4193X4, O4193X5, O4193X9, O641XX0, O641XX1, O641XX2, O641XX3, O641XX4, O641XX5, O641XX9, O642XX0, O642XX1, O642XX2, O642XX3, O642XX4, O642XX5, O642XX9, O643XX0, O643XX1, O643XX2, O643XX3, O643XX4, O643XX5, O643XX9, O644XX0, O644XX1, O644XX2, O644XX3, O644XX4, O644XX5, O644XX9, O645XX0, O645XX1, O645XX2, O645XX3, O645XX4, O645XX5, O645XX9, O648XX0, O648XX1, O648XX2, O648XX3, O648XX4, O648XX5, O648XX9, O649XX0, O649XX1, O649XX2, O649XX3, O649XX4, O649XX5, O649XX9, O650, O651, O652, O653, O654, O655, O658, O659, O640XX0, O640XX1, O640XX2, O640XX3, O640XX4, O640XX5, O640XX9, O660, O661, O6640, O6641, O662, O663, O666, O668, O669, O620, O621, O622, O623, O624, O628, O629, O630, O639, O631, O632, O690XX0, O690XX1, O690XX2, O690XX3, O690XX4, O690XX5, O690XX9, O691XX0, O691XX1, O691XX2, O691XX3, O691XX4, O691XX5, O691XX9, O692XX0, O692XX1, O692XX2, O692XX3, O692XX4, O692XX5, O692XX9, O6981X0, O6981X1, O6981X2, O6981X3, O6981X4, O6981X5, O6981X9, O6982X0, O6982X1, O6982X2, O6982X3, O6982X4, O6982X5, O6982X9, O6989X0, O6989X1, O6989X2, O6989X3, O6989X4, O6989X5, O6989X9, O693XX0, O693XX1, O693XX2, O693XX3, O693XX4, O693XX5, O693XX9, O694XX0, O694XX1, O694XX2, O694XX3, O694XX4, O694XX5, O694XX9, O695XX0, O695XX1, O695XX2, O695XX3, O695XX4, O695XX5, O695XX9, O43129, O43121, O43122, O43123, O699XX0, O699XX1, O699XX2, O699XX3, O699XX4, O699XX5, O699XX9, O665, O30029, O30021, O30022, O30023, P000, P001, P002, P003, P004, P005, P007, P006, P041, Q861, P042, P045, P046, P048, P049, Q862, Q868, P0081, P9681, P009, P010, P011, P012, P013, P014, P015, P016, P017, P018, P019, P020, P021, P0220, P0229, P023, P024, P025, P0260, P0269, P027, P028, P029, P030, P031, P032, P033, P034, P040, P035, P036, P03810, P03811, P03819, P0382, P0389, P039,

11 CABG Algorithm Summary v1.6 Page 11 of 25 Exclusion ICD-10-CM Diagnosis : P080, P081, P0821, P0822, P220, P230, P231, P232, P233, P234, P235, P236, P238, P239, P249, P2400, P2401, P2410, P2411, P2420, P2421, P2480, P2481, P250, P251, P252, P253, P258, P260, P261, P268, P269, P280, P2810, P2811, P2819, P221, P270, P271, P278, P279, P283, P284, P282, P285, P2430, P2431, P2881, P228, P229, P2889, P289, P350, P351, P352, P353, P358, P359, P370, P371, P372, P373, P374, P378, P379, A33, P381, P389, P390, P391, P375, P393, P392, P394, P398, P399, P500, P501, P502, P503, P504, P505, P508, P509, P102, P523, P520, P521, P5221, P5222, P103, P525, P510, P518, P519, P541, P542, P543, P544, P545, P540, P546, P548, P549, P550, P551, P558, P559, P560, P5690, P5699, P570, P580, P581, P582, P583, P5841, P5842, P585, P588, P589, P590, P598, P593, P591, P5920, P5929, P599, P578, P579, P700, P701, P702, P940, P721, P710, P711, P712, P713, P714, P718, P719, P741, P742, P743, P744, P703, P704, P740, P84, P708, P720, P722, P728, P745, P746, P748, P709, P729, P749, P53, P610, P60, P616, P611, P613, P614, P612, P615, P618, P619, P760, P762, P782, P761, P779, P771, P772, P773, P780, P768, P769, P781, P783, P7881, P7882, P7883, P7889, P789, P832, P830, P800, P808, P809, P810, P818, P819, P8330, P8339, P835, P834, P831, P836, P838, P839, P90, P918, P919, P910, P911, P913, P914, P915, P921, P922, P923, P924, P925, P928, P929, P9201, P9209, P926, P930, P938, P912, P2912, P2911, P9682, P9683, P2981, P290, P292, P294, P2989, P299, P941, P942, P948, P949, P960, P963, P965, P9689, P95, P969, R6812, R6811, R180, R1083, O289, R87614, R87620, R87621, R87622, R87623, R87624, R75, R85619, R85610, R85611, R85612, R85613, R85614, T510X1S, T510X2S, T510X3S, T510X4S, T511X1S, T511X2S, T511X3S, T511X4S, T512X1S, T512X2S, T512X3S, T512X4S, T513X1S, T513X2S, T513X3S, T513X4S, T518X1S, T518X2S, T518X3S, T518X4S, T5191XS, T5192XS, T5193XS, T5194XS, T520X1S, T520X2S, T520X3S, T520X4S, T521X1S, T521X2S, T521X3S, T521X4S, T522X1S, T522X2S, T522X3S, T522X4S, T523X1S, T523X2S, T523X3S, T523X4S, T524X1S, T524X2S, T524X3S, T524X4S, T528X1S, T528X2S, T528X3S, T528X4S, T5291XS, T5292XS, T5293XS, T5294XS, T530X1S, T530X2S, T530X3S, T530X4S, T531X1S, T531X2S, T531X3S, T531X4S, T532X1S, T532X2S, T532X3S, T532X4S, T533X1S, T533X2S, T533X3S, T533X4S, T534X1S, T534X2S, T534X3S, T534X4S, T535X1S, T535X2S, T535X3S, T535X4S, T536X1S, T536X2S, T536X3S, T536X4S, T537X1S, T537X2S, T537X3S, T537X4S, T5391XS, T5392XS, T5393XS, T5394XS, T540X1S, T540X2S, T540X3S, T540X4S, T541X1S, T541X2S, T541X3S, T541X4S, T542X1S, T542X2S, T542X3S, T542X4S, T543X1S, T543X2S, T543X3S, T543X4S, T5491XS, T5492XS, T5493XS, T5494XS, T550X1S, T550X2S, T550X3S, T550X4S, T551X1S, T551X2S, T551X3S, T551X4S, T560X1S, T560X2S, T560X3S, T560X4S, T561X1S, T561X2S, T561X3S, T561X4S, T562X1S, T562X2S, T562X3S, T562X4S, T563X1S, T563X2S, T563X3S, T563X4S, T564X1S, T564X2S, T564X3S, T564X4S, T565X1S, T565X2S, T565X3S, T565X4S, T566X1S, T566X2S, T566X3S, T566X4S, T567X1S, T567X2S, T567X3S, T567X4S, T56811S, T56812S, T56813S, T56814S, T56891S, T56892S, T56893S, T56894S, T5691XS, T5692XS, T5693XS, T5694XS, T570X1S, T570X2S, T570X3S, T570X4S, T571X1S, T571X2S, T571X3S, T571X4S, T572X1S, T572X2S, T572X3S, T572X4S, T573X1S, T573X2S, T573X3S, T573X4S, T578X1S, T578X2S, T578X3S, T578X4S, T5791XS, T5792XS, T5793XS, T5794XS, T5801XS, T5802XS, T5803XS, T5804XS, T5811XS, T5812XS, T5813XS, T5814XS, T582X1S, T582X2S, T582X3S, T582X4S, T588X1S, T588X2S, T588X3S, T588X4S, T5891XS, T5892XS, T5893XS, T5894XS, T590X1S, T590X2S, T590X3S, T590X4S, T591X1S, T591X2S, T591X3S, T591X4S, T592X1S, T592X2S, T592X3S, T592X4S, T593X1S, T593X2S, T593X3S, T593X4S, T594X1S, T594X2S, T594X3S, T594X4S, T595X1S, T595X2S, T595X3S, T595X4S, T596X1S, T596X2S, T596X3S, T596X4S, T597X1S, T597X2S, T597X3S, T597X4S, T59811S, T59812S, T59813S, T59814S, T59891S, T59892S, T59893S, T59894S, T5991XS, T5992XS, T5993XS, T5994XS, T600X1S, T600X2S, T600X3S, T600X4S, T601X1S, T601X2S, T601X3S, T601X4S, T602X1S, T602X2S, T602X3S, T602X4S, T603X1S, T603X2S, T603X3S, T603X4S, T604X1S, T604X2S, T604X3S, T604X4S, T608X1S, T608X2S, T608X3S, T608X4S, T6091XS, T6092XS, T6093XS, T6094XS, T6101XS, T6102XS, T6103XS, T6104XS, T6111XS, T6112XS, T6113XS, T6114XS, T61771S, T61772S, T61773S, T61774S, T61781S, T61782S, T61783S, T61784S, T618X1S, T618X2S, T618X3S, T618X4S, T6191XS, T6192XS, T6193XS, T6194XS, T620X1S, T620X2S, T620X3S, T620X4S, T621X1S, T621X2S, T621X3S, T621X4S, T622X1S, T622X2S, T622X3S, T622X4S, T628X1S, T628X2S, T628X3S, T628X4S, T6291XS, T6292XS, T6293XS, T6294XS, T63001S, T63002S, T63003S, T63004S, T63011S, T63012S, T63013S, T63014S, T63021S, T63022S, T63023S,

12 CABG Algorithm Summary v1.6 Page 12 of 25 Exclusion ICD-10-CM Diagnosis : T63024S, T63031S, T63032S, T63033S, T63034S, T63041S, T63042S, T63043S, T63044S, T63061S, T63062S, T63063S, T63064S, T63071S, T63072S, T63073S, T63074S, T63081S, T63082S, T63083S, T63084S, T63091S, T63092S, T63093S, T63094S, T63111S, T63112S, T63113S, T63114S, T63121S, T63122S, T63123S, T63124S, T63191S, T63192S, T63193S, T63194S, T632X1S, T632X2S, T632X3S, T632X4S, T63301S, T63302S, T63303S, T63304S, T63311S, T63312S, T63313S, T63314S, T63321S, T63322S, T63323S, T63324S, T63331S, T63332S, T63333S, T63334S, T63391S, T63392S, T63393S, T63394S, T63411S, T63412S, T63413S, T63414S, T63421S, T63422S, T63423S, T63424S, T63431S, T63432S, T63433S, T63434S, T63441S, T63442S, T63443S, T63444S, T63451S, T63452S, T63453S, T63454S, T63461S, T63462S, T63463S, T63464S, T63481S, T63482S, T63483S, T63484S, T63511S, T63512S, T63513S, T63514S, T63591S, T63592S, T63593S, T63594S, T63611S, T63612S, T63613S, T63614S, T63621S, T63622S, T63623S, T63624S, T63631S, T63632S, T63633S, T63634S, T63691S, T63692S, T63693S, T63694S, T63711S, T63712S, T63713S, T63714S, T63791S, T63792S, T63793S, T63794S, T63811S, T63812S, T63813S, T63814S, T63821S, T63822S, T63823S, T63824S, T63831S, T63832S, T63833S, T63834S, T63891S, T63892S, T63893S, T63894S, T6391XS, T6392XS, T6393XS, T6394XS, T6401XS, T6402XS, T6403XS, T6404XS, T6481XS, T6482XS, T6483XS, T6484XS, T650X1S, T650X2S, T650X3S, T650X4S, T651X1S, T651X2S, T651X3S, T651X4S, T65211S, T65212S, T65213S, T65214S, T65221S, T65222S, T65223S, T65224S, T65291S, T65292S, T65293S, T65294S, T653X1S, T653X2S, T653X3S, T653X4S, T654X1S, T654X2S, T654X3S, T654X4S, T655X1S, T655X2S, T655X3S, T655X4S, T656X1S, T656X2S, T656X3S, T656X4S, T65811S, T65812S, T65813S, T65814S, T65821S, T65822S, T65823S, T65824S, T65831S, T65832S, T65833S, T65834S, T65891S, T65892S, T65893S, T65894S, T6591XS, T6592XS, T6593XS, T6594XS, T511X1A, T511X2A, T511X3A, T511X4A, T512X1A, T512X2A, T512X3A, T512X4A, T513X1A, T513X2A, T513X3A, T513X4A, T518X1A, T518X2A, T518X3A, T518X4A, T5191XA, T5192XA, T5193XA, T5194XA, T520X1A, T520X2A, T520X3A, T520X4A, T521X1A, T521X2A, T521X3A, T521X4A, T522X1A, T522X2A, T522X3A, T522X4A, T653X1A, T653X2A, T653X3A, T653X4A, T530X1A, T530X2A, T530X3A, T530X4A, T654X1A, T654X2A, T654X3A, T654X4A, T531X1A, T531X2A, T531X3A, T531X4A, T532X1A, T532X2A, T532X3A, T532X4A, T533X1A, T533X2A, T533X3A, T533X4A, T534X1A, T534X2A, T534X3A, T534X4A, T536X1A, T536X2A, T536X3A, T536X4A, T537X1A, T537X2A, T537X3A, T537X4A, T5391XA, T5392XA, T5394XA, T523X1A, T523X2A, T523X3A, T523X4A, T524X1A, T524X2A, T524X3A, T524X4A, T528X1A, T528X2A, T528X3A, T528X4A, T5291XA, T5292XA, T5293XA, T5294XA, T540X1A, T540X2A, T540X3A, T540X4A, T542X1A, T542X2A, T542X3A, T542X4A, T543X1A, T543X2A, T543X3A, T543X4A, T541X1A, T541X2A, T541X3A, T541X4A, T5491XA, T5492XA, T5493XA, T5494XA, T571X1A, T571X2A, T571X3A, T571X4A, M1A10X0, M1A10X1, M1A1110, M1A1111, M1A1120, M1A1121, M1A1190, M1A1191, M1A1210, M1A1211, M1A1220, M1A1221, M1A1290, M1A1291, M1A1310, M1A1311, M1A1320, M1A1321, M1A1390, M1A1391, M1A1410, M1A1411, M1A1420, M1A1421, M1A1490, M1A1491, M1A1510, M1A1511, M1A1520, M1A1521, M1A1590, M1A1591, M1A1610, M1A1611, M1A1620, M1A1621, M1A1690, M1A1691, M1A1710, M1A1711, M1A1720, M1A1721, M1A1790, M1A1791, M1A18X0, M1A18X1, M1A19X0, M1A19X1, T560X1A, T560X2A, T560X3A, T560X4A, T561X1A, T561X2A, T561X3A, T561X4A, T570X1A, T570X2A, T570X3A, T570X4A, T572X1A, T572X2A, T572X3A, T572X4A, T567X1A, T567X2A, T567X3A, T567X4A, T563X1A, T563X2A, T563X3A, T563X4A, T562X1A, T562X2A, T562X3A, T562X4A, T564X1A, T564X2A, T564X3A, T564X4A, T565X1A, T565X2A, T565X3A, T565X4A, T566X1A, T566X2A, T566X3A, T566X4A, T56811A, T56812A, T56813A, T56814A, T56891A, T56892A, T56893A, T56894A, T5691XA, T5692XA, T5693XA, T5694XA, T5801XA, T5802XA, T5803XA, T5804XA, T5811XA, T5812XA, T5813XA, T5814XA, T582X1A, T582X2A, T582X3A, T582X4A, T588X1A, T588X2A, T588X3A, T588X4A, T5891XA, T5892XA, T5893XA, T5894XA, T592X1A, T592X2A, T592X3A, T592X4A, T590X1A, T590X2A, T590X3A, T590X4A, T591X1A, T591X2A, T591X3A, T591X4A, T535X1A, T535X2A, T535X3A, T535X4A, T593X1A, T593X2A, T593X3A, T593X4A, T594X1A, T594X2A, T594X3A, T594X4A, T573X1A, T573X2A, T573X3A, T573X4A, T595X1A, T595X2A, T595X3A, T595X4A, T596X1A, T596X2A, T596X3A, T596X4A, T597X1A, T597X2A, T597X3A, T597X4A, T59811A, T59812A, T59813A, T59814A, T59891A, T59892A, T59893A, T59894A, T5991XA, T5992XA, T5993XA, T5994XA, T6101XA, T6102XA, T6103XA, T6104XA, T6111XA, T6112XA, T6113XA, T6114XA, T61771A,

13 CABG Algorithm Summary v1.6 Page 13 of 25 Exclusion ICD-10-CM Diagnosis : T61772A, T61773A, T61774A, T61781A, T61782A, T61783A, T61784A, T618X1A, T618X2A, T618X3A, T618X4A, T6191XA, T6192XA, T6193XA, T6194XA, T620X1A, T620X2A, T620X3A, T620X4A, T621X1A, T621X2A, T621X3A, T621X4A, T622X1A, T622X2A, T622X3A, T622X4A, T628X1A, T628X2A, T628X3A, T628X4A, T6291XA, T6292XA, T6293XA, T6294XA, T650X1A, T650X2A, T650X3A, T650X4A, T651X1A, T651X2A, T651X3A, T651X4A, T5393XA, T600X1A, T600X2A, T600X3A, T600X4A, T601X1A, T601X2A, T601X3A, T601X4A, T602X1A, T602X2A, T602X3A, T602X4A, T604X1A, T604X2A, T604X3A, T604X4A, T608X1A, T608X2A, T608X3A, T608X4A, T6091XA, T6092XA, T6093XA, T6094XA, T63001A, T63002A, T63003A, T63004A, T63011A, T63012A, T63013A, T63014A, T63021A, T63022A, T63023A, T63024A, T63031A, T63032A, T63033A, T63034A, T63041A, T63042A, T63043A, T63044A, T63061A, T63062A, T63063A, T63064A, T63071A, T63072A, T63073A, T63074A, T63081A, T63082A, T63083A, T63084A, T63091A, T63092A, T63093A, T63094A, T63111A, T63112A, T63113A, T63114A, T63121A, T63122A, T63123A, T63124A, T63191A, T63192A, T63193A, T63194A, T632X1A, T632X2A, T632X3A, T632X4A, T63301A, T63302A, T63303A, T63304A, T63311A, T63312A, T63313A, T63314A, T63321A, T63322A, T63323A, T63324A, T63331A, T63332A, T63333A, T63334A, T63391A, T63392A, T63393A, T63394A, T63411A, T63412A, T63413A, T63414A, T63421A, T63422A, T63423A, T63424A, T63431A, T63432A, T63433A, T63434A, T63441A, T63442A, T63443A, T63444A, T63451A, T63452A, T63453A, T63454A, T63461A, T63462A, T63463A, T63464A, T63481A, T63482A, T63483A, T63484A, T63511A, T63512A, T63513A, T63514A, T63591A, T63592A, T63593A, T63594A, T63611A, T63612A, T63613A, T63614A, T63621A, T63622A, T63623A, T63624A, T63631A, T63632A, T63633A, T63634A, T63691A, T63692A, T63693A, T63694A, T63711A, T63712A, T63713A, T63714A, T63791A, T63792A, T63793A, T63794A, T63811A, T63812A, T63813A, T63814A, T63821A, T63822A, T63823A, T63824A, T63831A, T63832A, T63833A, T63834A, T63891A, T63892A, T63893A, T63894A, T6391XA, T6392XA, T6393XA, T6394XA, T550X1A, T550X2A, T550X3A, T550X4A, T551X1A, T551X2A, T551X3A, T551X4A, T6401XA, T6402XA, T6403XA, T6404XA, T6481XA, T6482XA, T6483XA, T6484XA, T65811A, T65812A, T65813A, T65814A, T65211A, T65212A, T65213A, T65214A, T65221A, T65222A, T65223A, T65224A, T65291A, T65292A, T65293A, T65294A, T578X1A, T578X2A, T578X3A, T578X4A, T603X1A, T603X2A, T603X3A, T603X4A, T655X1A, T655X2A, T655X3A, T655X4A, T656X1A, T656X2A, T656X3A, T656X4A, T65821A, T65822A, T65823A, T65824A, T65831A, T65832A, T65833A, T65834A, T65891A, T65892A, T65893A, T65894A, T5791XA, T5792XA, T5793XA, T5794XA, T6591XA, T6592XA, T6593XA, T6594XA, T8690, T8691, T8692, T8693, T8699, T8610, T8611, T8612, T8613, T8619, T8640, T8641, T8642, T8643, T8649, T8620, T8621, T8622, T8623, T86290, T86298, T8630, T8631, T8632, T8633, T8639, T8630, T8631, T8632, T8633, T8639, T86810, T86811, T86812, T86818, T86819, T8600, T8601, T8602, T8603, T8609, T86890, T86891, T86892, T86898, T86899, T86850, T86851, T86852, T86858, T86859, T865, T86830, T86831, T86832, T86838, T86839, T39012A, T39092A, T392X2A, T39312A, T39392A, T394X2A, T398X2A, T3992XA, T400X2A, T401X2A, T403X2A, T411X2A, T41202A, T41292A, T413X2A, T4142XA, T407X2A, T408X2A, T40902A, T40992A, T4272XA, T43012A, T43022A, T431X2A, T43202A, T43212A, T43222A, T43292A, T433X2A, T434X2A, T43502A, T43592A, T43602A, T43612A, T43622A, T43632A, T43692A, T438X2A, T4392XA, T360X2A, T361X2A, T362X2A, T363X2A, T364X2A, T365X2A, T366X2A, T367X2A, T368X2A, T3692XA, T370X2A, T371X2A, T372X2A, T373X2A, T374X2A, T375X2A, T378X2A, T3792XA, T380X2A, T381X2A, T382X2A, T383X2A, T384X2A, T385X2A, T386X2A, T387X2A, T38802A, T38812A, T38892A, T38902A, T38992A, T405X2A, T420X2A, T421X2A, T422X2A, T425X2A, T426X2A, T428X2A, T440X2A, T441X2A, T442X2A, T443X2A, T444X2A, T445X2A, T446X2A, T447X2A, T448X2A, T44902A, T44992A, T450X2A, T451X2A, T452X2A, T453X2A, T454X2A, T45512A, T45522A, T45602A, T45612A, T45622A, T45692A, T457X2A, T458X2A, T4592XA, T460X2A, T461X2A, T462X2A, T463X2A, T464X2A, T465X2A, T466X2A, T467X2A, T468X2A, T46902A, T46992A, T470X2A, T471X2A, T472X2A, T473X2A, T474X2A, T475X2A, T476X2A, T477X2A, T478X2A, T4792XA, T480X2A, T481X2A, T48202A, T48292A, T483X2A, T484X2A, T485X2A, T486X2A, T48902A, T48992A, T490X2A, T491X2A, T492X2A, T493X2A, T494X2A, T495X2A, T496X2A, T497X2A, T498X2A, T4992XA, T500X2A, T501X2A, T502X2A, T503X2A, T504X2A, T505X2A, T506X2A, T507X2A, T508X2A, T50902A, T50992A, T50A12A, T50A22A, T50A92A, T50B12A, T50B92A, T50Z12A, T50Z92A, T600X2A, T540X2A, T542X2A, T550X2A, T551X2A, T572X2A, T510X2A,

14 CABG Algorithm Summary v1.6 Page 14 of 25 Exclusion ICD-10-CM Diagnosis: T511X2A, T512X2A, T513X2A, T518X2A, T5192XA, T520X2A, T521X2A, T522X2A, T523X2A, T524X2A, T528X2A, T5292XA, T530X2A, T531X2A, T532X2A, T533X2A, T534X2A, T536X2A, T537X2A, T5392XA, T560X2A, T561X2A, T562X2A, T563X2A, T564X2A, T565X2A, T566X2A, T567X2A, T56812A, T56892A, T5692XA, T578X2A, T5792XA, T6102XA, T6112XA, T61772A, T61782A, T618X2A, T6192XA, T620X2A, T621X2A, T622X2A, T628X2A, T6292XA, T6402XA, T6482XA, T650X2A, T651X2A, T65212A, T65222A, T65292A, T653X2A, T654X2A, T655X2A, T656X2A, T65812A, T65822A, T65832A, T65892A, T6592XA, T410X2A, T415X2A, T535X2A, T573X2A, T590X2A, T591X2A, T593X2A, T59892A, T71162A, T71112A, X710XXA, X710XXD, X711XXA, X711XXD, X712XXA, X712XXD, X713XXA, X713XXD, X718XXA, X718XXD, X719XXA, X719XXD, X72XXXA, X72XXXD, X730XXA, X730XXD, X731XXA, X731XXD, X732XXA, X732XXD, X738XXA, X738XXD, X739XXA, X739XXD, X748XXA, X748XXD, X75XXXA, X75XXXD, X7401XA, X7401XD, X7409XA, X7409XD, X7402XA, X7402XD, X749XXA, X749XXD, X780XXA, X780XXD, X781XXA, X781XXD, X782XXA, X782XXD, X788XXA, X788XXD, X789XXA, X789XXD, X80XXXA, X80XXXD, X810XXA, X810XXD, X811XXA, X811XXD, X818XXA, X818XXD, X76XXXA, X76XXXD, X773XXA, X773XXD, X778XXA, X778XXD, X779XXA, X779XXD, X770XXA, X770XXD, X771XXA, X771XXD, X772XXA, X772XXD, X832XXA, X832XXD, X831XXA, X831XXD, X820XXA, X820XXD, X821XXA, X821XXD, X822XXA, X822XXD, X828XXA, X828XXD, X830XXA, X830XXD, X79XXXA, X79XXXD, X838XXA, X838XXD, T1491, Z21, Z8500, Z85810, Z85818, Z85819, Z8501, Z85028, Z85038, Z85048, Z8505, Z85068, Z8507, Z8509, Z85118, Z8512, Z8520, Z8521, Z8522, Z85238, Z8529, Z853, Z8540, Z8541, Z8542, Z8543, Z8544, Z8545, Z8546, Z8547, Z8548, Z8549, Z8550, Z8551, Z85528, Z8553, Z8554, Z8559, Z856, Z8571, Z8572, Z8579, Z85830, Z85820, Z85840, Z85841, Z85848, Z85850, Z85858, Z85831, Z8589, Z859, Z85020, Z85030, Z85040, Z85060, Z85110, Z85230, Z85520, Z85821, Z4822, Z940, Z4821, Z48280, Z941, Z943, Z947, Z4823, Z944, Z992, Z9115, Z412, Z4931, Z4901, Z4902, Z4931, Z4932, Z510, Z5111, Z5112, R45851, Z08 Patients who have co-morbid condition(s) indicated by the following will be excluded: ICD-9-CM Diagnosis: V45.1, V45.11, V45.12, V50.2, V56, V56.0, V56.1, V56.2, V56.3, V56.31, V56.32, V56.8, V58.0, V58.1, V58.11, V58.12, V62.84, V66.1, V66.2, V67.1, V67.2, V71.1 ICD-10-CM Diagnosis: R45851, Z08, Z412, Z4901, Z4902, Z4931, Z4932, Z510, Z5111, Z5112, Z9115, Z992 ICD-9 Procedure: 00.40, 00.41, 00.42, 00.43, 00.44, 00.66, 36.01, 36.02, 36.04, 36.05, ICD-10-CM Diagnosis: , Z, 02723D6, 02723DZ, 02723T6, 02723TZ, 02723Z6, 02723ZZ, , Z, 02724D6, 02724DZ, 02724T6, 02723ZZ, , Z, 02724D6, 02724DZ, 02724T6, 02724TZ, 02724Z6, 02724ZZ, , Z, 02733D6, DZ, 02733T6, 02733TZ, 02733Z6, 02733ZZ, , Z, 02733D6, 02733DZ, 02733T6, 02733TZ, 02733Z6, 02733ZZ, , Z, 02734D6, 02734DZ, 02734T6, 02734TZ, 02734Z6, 02734ZZ, 02C03ZZ, 02C04ZZ, 02C13ZZ, 02C14ZZ, 02C23ZZ, 02C24ZZ, 02C33ZZ, 02C34ZZ, 3E07017, 3E070PZ, 3E07317, 3E073PZ, A030, A031, A032, A033, A067, H449 Included In addition to all inpatient facility claims, claims with one of the following are included when performed in an inpatient professional, emergency room, skilled nursing facility, or comprehensive inpatient rehab facility: ICD-9 Procedure: 00.40, 00.41, 00.42, 00.43, 00.44, 00.45, 00.46, 00.47, 00.48, 00.50, 00.51, 00.52, 00.53, 00.54, 00.66, 35.10, 35.11, , 36.14, 36.15, 36.16, 36.17, 36.19, 36.2, 36822, 37.0, 37.21, 37.22, 37.23, 37.26, 37.27, 37.29, 37.32, 37.33, 37.34, 37.35, 37.36, 37.60, 37.61, 37.62, 37.63, 37.64, 37.65, 37.66, 37.67, 37.68, 37.70, 37.71, 37.72, 37.73, 37.74, 37.75, 37.76, 37.77, 37.78, 37.79, 37.80, 37.81, 37.82, 37.83, 37.85, 37.86, 37.87, 37.89, 37.94, 37.95, 37.96, 37.97, 37.98, 37.99, 38.05, 38.12, 38.35, 38.45, 39.54, 39.61, 39.62, 39.63, 39.64, 39.65, 39.66, 49.00, 54.61, 54.62, 84.49, 86.04, 86.22, 86.28, 86.59, 87.44, 88.4, 88.40, 88.41, 88.42, 88.43, 88.44, 88.45, 88.46, 88.47, 88.48,