Cal. Code Regs. tit. 22 § 97174

Current through Register 2024 Notice Reg. No. 43, October 25, 2024

Section 97174 - Required Data Elements

(a) For patients discharged on or after July 1, 2020, a hospital shall submit the following data elements for each CABG surgery in compliance with the California CABG Outcomes Reporting Program (CCORP) Data Element Specifications Version 8.3, dated June 29, 2020, hereby incorporated by reference. This document is available for download from the OSHPD website. The office will make a hardcopy available on request. For all data elements categorized as postoperative events, with the exception of Deep Sternal, report only if the postoperative event occurred during the hospitalization for CABG surgery.

(1) Medical Record Number,

(2) Type of CABG,

(3) Date of Surgery,

(4) Date of Birth,

(5) Patient Age,

(6) Sex,

(7) Primary Payor,

(8) Secondary (Supplemental) Payor,

(9) Race Documented,

(10) Race -- White,

(11) Race -- Black/African American,

(12) Race -- Asian,

(13) Race -- American Indian/Alaskan Native,

(14) Race -- Native Hawaiian/Pacific Islander,

(15) Race -- Other,

(16) Hispanic or Latino or Spanish Ethnicity,

(17) Hospital Discharge Date,

(19) Patient Transfer to Another Acute Hospital,

(20) Patient Transferred to Acute Hospital -- Date,

(21) Mortality Date,

(22) Mort -- Status at 30 Days After Surgery (either discharged or in-hospital),

(23) Responsible Surgeon Name (3 separate fields),

(24) Responsible Surgeon CA License Number,

(25) Height (cm),

(26) Weight (kg),

(27) Diabetes,

(28) Diabetes Control,

(29) Dialysis,

(30) Hypertension,

(31) Endocarditis,

(32) Infectious Endocarditis Type,

(33) Chronic Lung Disease,

(34) Pneumonia,

(35) Liver Disease,

(36) Immunocompromised Present,

(37) COVID-19

(38) Cancer within 5 years,

(39) Peripheral Artery Disease,

(40) Cerebrovascular Disease,

(41) Prior CVA,

(42) Prior CVA When,

(43) CVD TIA,

(44) CVD -- Carotid Stenosis,

(45) CVD Carotid Stenosis -- Right,

(46) CVD Carotid Stenosis -- Left,

(47) CVD Prior Carotid Surgery,

(48) Last Creatinine Level,

(49) Total Albumin,

(50) Total Bilirubin,

(51) INR,

(52) Sodium,

(53) Previous CABG,

(54) Previous Valve,

(55) Previous PCI,

(56) Previous PCI -- Interval,

(57) Prior MI,

(58) MI -- When,

(59) Heart Failure,

(60) Heart Failure Timing,

(61) Classification -- NYHA,

(62) Cardiogenic Shock,

(63) Resuscitation,

(64) Cardiac Arrhythmia,

(65) Cardiac Arrhythmia -- Vtach/Vfib,

(66) Cardiac Arrhythmia -- Aflutter,

(67) Cardiac Arrhythmia -- Third Degree Heart Block,

(68) Cardiac Arrhythmia -- Atrial Fibrillation,

(69) Atrial Fibrillation-Type,

(70) Warfarin Use (within 5 days),

(71) Coronary Anatomy/Disease Known,

(72) Number Diseased Vessels,

(73) Left Main Stenosis >= 50% Known,

(74) Hemo Data EF Done,

(75) Hemo Data EF,

(76) PA Systolic Pressure Measured,

(77) PA Systolic Pressure,

(78) Mitral Valve Regurgitation,

(79) Mitral Regurgitation,

(80) Incidence,

(81) Status,

(82) Urgent / Emergent/Emergent Salvage Reason,

(83) Perfusion Strategy,

(84) CPB Utilization -- Combination Plan,

(85) Internal Mammary Artery Used,

(86) Reason for No IMA,

(87) Valve,

(88) Aortic Valve,

(89) Aortic Valve Procedure Performed,

(90) Mitral Valve,

(91) Mitral Valve Procedure,

(92) Tricuspid Valve,

(93) Pulmonic Valve,

(94) Reoperation for Bleed/ Tampanade,

(95) Unplanned Coronary Artery Intervention,

(96) Unplanned Coronary Artery Intervention-Vessels,

(97) Deep Sternal,

(98) Neuro-Stroke Permanent,

(99) Pulm -- Ventilation Prolonged,

(100) Renal -- Renal Failure,

(101) Renal -- Dialysis Requirement,

(102) Other -- A Fib,

(103) Facility Identification Number

(b) If a value for a data element, other than data elements specified in Subsection (b)(1), is unknown or not applicable, a hospital may submit the record without a valid value for that data element.

(1) A valid value must be submitted for the following data elements: Medical Record Number, Type of CABG, Date of Surgery, Sex, Hospital Discharge Date, Status at Hospital Discharge, Responsible Surgeon Name, Responsible Surgeon CA License Number, Dialysis, Previous CABG, Previous PCI, Status, Reoperation for Bleed/Tamponade, Unplanned Coronary Artery Intervention, Deep Sternal, Neuro -- Stroke Permanent, Pulm -- Ventilation Prolonged, Renal -- Renal Failure, Renal -- Dialysis Requirement, Other -- A Fib, and Facility Identification Number.

(c) For patients discharged on or after January 1, 2018 through June 30, 2020, a hospital shall submit the following data elements for each CABG surgery in compliance with the California CABG Outcomes Reporting Program (CCORP) Data Element Specifications Version 7.1, dated May 5, 2019, hereby incorporated by reference. This document is available for download from the OSHPD website. The office will make a hardcopy available on request. For all data elements categorized as postoperative events, with the exception of Deep Sternal Infection/Mediastinitis, report only if the postoperative event occurred during the hospitalization for CABG surgery.

(1) Medical Record Number,

(2) Type of Coronary Artery Bypass Graft (CABG),

(3) Date of Surgery,

(4) Date of Birth,

(5) Patient Age,

(6) Sex,

(7) Race Documented,

(8) Race -- White,

(9) Race -- Black/African American,

(10) Race -- Asian,

(11) Race -- American Indian/Alaskan Native,

(12) Race -- Native Hawaiian/Pacific Islander,

(13) Race -- Other,

(14) Hispanic or Latino or Spanish Ethnicity,

(15) Date of Discharge,

(16) Discharge/Mortality Status,

(17) Mortality Date,

(18) Responsible Surgeon Name (3 separate fields),

(19) Responsible Surgeon CA License Number,

(20) Height (cm),

(21) Weight (kg),

(22) Diabetes,

(23) Diabetes Control,

(24) Dialysis,

(25) Hypertension,

(26) Endocarditis,

(27) Infectious Endocarditis Type,

(28) Chronic Lung Disease,

(29) Liver Disease,

(30) Immunocompromise,

(31) Peripheral Arterial Disease,

(32) Cerebrovascular Disease,

(33) Prior CVA,

(34) Prior CVA -- When,

(35) CVD TIA,

(36) CVD Carotid Stenosis,

(37) CVD Carotid Stenosis -- Right,

(38) CVD Carotid Stenosis -- Left,

(39) CVD Prior Carotid Surgery,

(40) Last Creatinine Level,

(41) Total Albumin,

(42) Total Bilirubin,

(43) INR,

(44) Previous CABG,

(45) Previous Valve,

(46) Previous PCI,

(47) Previous PCI -- Interval,

(48) Prior MI,

(49) MI -- When,

(50) Heart Failure,

(51) Heart Failure Timing,

(52) Classification -- NYHA,

(53) Cardiogenic Shock,

(54) Resuscitation,

(55) Cardiac Arrhythmia,

(56) Cardiac Arrhythmia -- VTach/VFib,

(57) Cardiac Arrhythmia -- Aflutter,

(58) Cardiac Arrhythmia -- Third Degree Heart Block,

(59) Cardiac Arrhythmia -- Atrial fibrillation,

(60) Cardiac Arrhythmia -- Atrial fibrillation Type,

(61) Warfarin Use (within 5 days),

(62) Coronary Anatomy/Disease Known,

(63) Number of Diseased Vessels,

(64) Percent Native Artery Stenosis Known,

(65) Percent Stenosis -- Left Main,

(66) Ejection Fraction Done,

(67) Ejection Fraction (%),

(68) PA Systolic Pressure Measured,

(69) PA Systolic Pressure,

(70) Insufficiency -- Mitral,

(71) Incidence,

(72) Status,

(73) Urgent Or Emergent Reason,

(74) CPB Utilization,

(75) CPB Utilization -- Combination Plan,

(76) IMA Artery Used,

(77) Reason for No IMA,

(78) Valve,

(79) Aortic Valve,

(80) Aortic Valve Procedure,

(81) Mitral Valve,

(82) Mitral Valve Procedure,

(83) Tricuspid Valve,

(84) Pulmonic Valve,

(85) Reoperation for Bleed,

(86) Reintervention -- Myocardial Ischemia,

(87) Reintervention -- Myocardial Ischemia Vessel,

(88) Deep Sternal Infection/Mediastinitis,

(89) Neuro -- Stroke Permanent,

(90) Pulm -- Ventilation Prolonged,

(91) Renal -- Renal Failure,

(92) Renal -- Dialysis Requirement,

(93) Other -- A Fib,

(94) Facility Identification Number,

(d) If a value for a data element, other than data elements specified in Subsection (d)(1), is unknown or not applicable, a hospital may submit the record without a valid value for that data element.

(1) A valid value must be submitted for the following data elements: Medical Record Number, Type of CABG, Date of Surgery, Sex, Date of Discharge, Discharge Status, Responsible Surgeon Name, Responsible Surgeon CA License Number, Dialysis, Previous PCI, Status, Reoperation for Bleed, Reintervention -- Myocardial Ischemia, Reintervention -- Myocardial Ischemia Vessel, Deep Sternal Infection/Mediastinitis, Neuro -- Stroke Permanent, Pulm -- Ventilation Prolonged, Renal -- Renal Failure, Renal -- Dialysis Requirement, Other -- A Fib, and Facility Identification Number.

Cal. Code Regs. Tit. 22, § 97174

1. New section filed 4-29-2003; operative 4-29-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 18).
2. Amendment filed 2-2-2006; operative 3-4-2006 (Register 2006, No. 5).
3. New subsections (a)-(a)(85)(D), subsection relettering and amendment of newly designated subsection (b) filed 1-29-2009; operative 2-28-2009 (Register 2009, No. 5).
4. Repealer of subsections (b)-(b)(59)(C), subsection relettering and amendment of newly designated subsections (b) and (b)(1) filed 2-24-2010; operative 2-24-2010 pursuant to Government Code section 11343.4 (Register 2010, No. 9).
5. New subsections (a)-(b)(1), subsection relettering and amendment of newly designated subsections (c) and (d) filed 4-11-2012; operative 4-11-2012 pursuant to Government Code section 11343.4 (Register 2012, No. 15).
6. New subsections (a)-(b), repealer of subsections (c)-(d), subsection relettering and amendment of newly designated subsections (c) and (d) filed 12-31-2014; operative 1-1-2015 pursuant to Government Code section 11343.4(b)(3) (Register 2015, No. 1).
7. Editorial correction designating paragraph following subsection (a)(23)(A) as (a)(23)(B) and relettering subsections (Register 2015, No. 34).
8. Editorial correction of subsection (a)(28)(D)(iv) (Register 2015, No. 34).
9. Change without regulatory effect amending subsections (a)(20)(D), (a)(21)(D), (a)(26)(D)(ii)4., (a)(66)(D)(i)2. and (a)(72)(B) filed 8-17-2015 pursuant to section 100, title 1, California Code of Regulations (Register 2015, No. 34).
10. New subsections (a)-(b)(1), subsection relettering and amendment of newly designated subsections (c), (c)(2)(D), (c)(2)(D)(ii)(g), (d), (e)(2)(D), (e)(2)(D)(ii) and (f) filed 9-16-2016; operative 9-16-2016 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 38).
11. Editorial correction of subsection (c)(2)(D)(i) (Register 2016, No. 49).
12. Change without regulatory effect repealing subsections (e)-(f)(1) filed 11-30-2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 49).
13. New subsections (a)-(b)(1), repealer of subsections (c)-(d)(1), subsection relettering and amendment of newly designated subsections (c) and (d) filed 6-20-2018; operative 7-1-2018 pursuant to Government Code section 11343.4(b)(3) (Register 2018, No. 25).
14. Change without regulatory effect amending section filed 7-29-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 31).
15. New subsection (a)-(b)(1), subsection relettering and amendment of newly designated subsection (c) filed 12-7-2020; operative 12-7-2020 pursuant to Government Code section 11343.4(b)(3) (Register 2020, No. 50).

Note: Authority cited: Section 128810, Health and Safety Code. Reference: Section 128745, Health and Safety Code.

1. New section filed 4-29-2003; operative 4-29-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 18).
2. Amendment filed 2-2-2006; operative 3-4-2006 (Register 2006, No. 5).
3. New subsections (a)-(a)(85)(D), subsection relettering and amendment of newly designated subsection (b) filed 1-29-2009; operative 2-28-2009 (Register 2009, No. 5).
4. Repealer of subsections (b)-(b)(59)(C), subsection relettering and amendment of newly designated subsections (b) and (b)(1) filed 2-24-2010; operative 2-24-2010 pursuant to Government Code section 11343.4 (Register 2010, No. 9).
5. New subsections (a)-(b)(1), subsection relettering and amendment of newly designated subsections (c) and (d) filed 4-11-2012; operative 4-11-2012 pursuant to Government Code section 11343.4 (Register 2012, No. 15).
6. New subsections (a)-(b), repealer of subsections (c)-(d), subsection relettering and amendment of newly designated subsections (c) and (d) filed 12-31-2014; operative 1/1/2015 pursuant to Government Code section 11343.4(b)(3) (Register 2015, No. 1).
7. Editorial correction designating paragraph following subsection (a)(23)(A) as (a)(23)(B) and relettering subsections (Register 2015, No. 34).
8. Editorial correction of subsection (a)(28)(D)(iv) (Register 2015, No. 34).
9. Change without regulatory effect amending subsections (a)(20)(D), (a)(21)(D), (a)(26)(D)(ii)4., (a)(66)(D)(i)2. and (a)(72)(B) filed 8-17-2015 pursuant to section 100, title 1, California Code of Regulations (Register 2015, No. 34).
10. New subsections (a)-(b)(1), subsection relettering and amendment of newly designated subsections (c), (c)(2)(D), (c)(2)(D)(ii)(g), (d), (e)(2)(D), (e)(2)(D)(ii) and (f) filed 9-16-2016; operative 9/16/2016 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 38).
11. Editorial correction of subsection (c)(2)(D)(i) (Register 2016, No. 49).
12. Change without regulatory effect repealing subsections (e)-(f)(1) filed 11/30/2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 50).
13. New subsections (a)-(b)(1), repealer of subsections (c)-(d)(1), subsection relettering and amendment of newly designated subsections (c) and (d) filed 6-20-2018; operative 7/1/2018 pursuant to Government Code section 11343.4(b)(3) (Register 2018, No. 25).
14. Change without regulatory effect amending section filed 7-29-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 31).
15. New subsection (a)-(b)(1), subsection relettering and amendment of newly designated subsection (c) filed 12-7-2020; operative 12/7/2020 pursuant to Government Code section 11343.4(b)(3) (Register 2020, No. 50).