Audit Summary for Client

ICD General Statement

-All pages referenced are related to the medical records

The statements below were found consistently throughout the ICD Audit Process;

Device Returned to Manufacturer (6235). CRS: Yes Client: No. Typically the device company takes these generators that are changed out.

Would recommend EP Physicians document Primary or Secondary and NYHA Functional Class. This is a requirement of NCDR and coming from CMS.

Prophylactic ABX w/in 1 hour of Procedure Start Time  I see this on the Cath Lab Log, but would suggest this should also be documented in your MAR also. There seems to be inconsistencies on this documentation. I would also suggest you talk to whoever is doing your Core measures and see what their findings are. It would be a strong suggestion to have the ABX documentation one consistent place.

It appears in the Apollo print out, we only received information on one lead for each case. So if patient was a Dual or CRTD we only had one lead to audit.

Most of the leads are coded “Other”. Other is rarely used for coding. I am not sure why coding of other is used and would check with your EP Physicians and see if they wanted them coded that way?

Would suggest you always have the device report from Manufacture Representative for clarification of device and leads. Also it is helpful to have the stickers for the newly implanted device and leads for the abstractors.

Sleep Apnea  Most abstractors code “Not Assessed”. I found 80% of the time the abstractors were correct. I would just do a review of this complicated definition. NCDR detailed FAQ states;

  • No = There is no documentation of sleep apnea in the patient medical record.

Yes = There is positive documentation the patient has sleep apnea that has been diagnosed by a sleep study. With documentation of sleep apnea a patient on CPAP may equate with evidence that a sleep study has been performed and coding may reflect “Yes” for sequence # 4250 without having to have an actual sleep study contained in the medical record.

Not assessed = There is a documentation of sleep apnea, but the patient has not had a sleep study performed. No documentation of CPAP.

Leads only form: We only audited one patient that required only the 3 page lead only form. It appeared from the Apollo printout that a full 5 page Generator and leads form was filled out. I would recommend you look at the criteria for the full 5 pages and the 3 page lead only form.