CMS - 10151 ACC-NCDR - ICD Registry Data Collection Form - REVISED

ACC-NCDR® ICD Registry™v1.08 Data Collection Form
IMPLANT
A.

PARTICIPANT ADMINISTRATION:
Participant ID1000/Name1010: _______________________ Medicare Provider #1015: ___________

B.

Participant NPI1016: ___________________

DEMOGRAPHICS:
Last Name2000: ___________________________
First Name2010: _________________________
2030
SSN : ______________________
Unique Patient Id2040: ______________________(automatic)

Middle Name2020: ___________________
Other ID2045: _____________________

Gender2060:
Male;
Female
Date of Birth2050: _____/_____/________
2070
Race :
White;
Black/African American;
Asian;
American Indian/Alaska Native;
Native Hawaiian;
Other
Hispanic Ethnicity2075:
No;
Yes
Auxiliary 12080: ____________________________________
Auxiliary 22090: ____________________________________________

C.

ADMISSION:
Admission Date3000: _____/_____/________
3020

:

Insurance Payor-Primary

Date of Implant3010: _____/_____/________

Government;

Commercial;

HMO;

None/Self Pay
None/Self Pay

Medicare;
→ if Government, Type-Secondary 3029:
Reason for Admission3030:
Admitted for this Procedure;

Non-Cardiac

Medicaid;

TriCare;

Federal Employee Insurance

VA Health Plan;

Cardiac-CHF;

Auxiliary 33040: ____________________________________

D.

Non-U.S. Insurance;

→ if Government, Type-Primary 3025:
Medicare;
Medicaid;
TriCare;
VA Health Plan;
Insurance Payor-Secondary3027:
Government;
Commercial;
HMO;
Non-U.S. Insurance;
Cardiac-Other;

Federal Employee Insurance

Auxiliary 43050: ____________________________________

HISTORY AND RISK FACTORS:
Syncope3060:

No;

Yes

3080

No;

Yes

CHF

:

→ if Yes, CHF Duration3090:

Family Hx Sudden Death3070:
Within the past 3 months;

→ if Yes , Prior CHF Hospitalization3095:
NYHA Functional Class (Current Status)3100:
Cardiac Arrest 3110:

No;

No Arrest;

3 to 9 months;

Not Hospitalized;
Class I;

Brady Arrest;

Yes
Greater than 9 months

Yes-Within 6 months;

Class II;

Class III;

Yes-Greater than 6 months
Class IV

Tachy Arrest

→ if Brady Arrest, Brady Arrest Reason 3111: (Check all that apply)
❒ Acute MI

❒ Severe Electrolyte Disturbance

❒ Drug Induced Arrhythmia

❒ Sinus Node Dysfunction/AV Block

❒ Unknown Etiology
→ if Tachy Arrest, Tachy Arrest Reason 3112: (Check all that apply)
❒ Acute MI

❒ Severe Electrolyte Disturbance

❒ Drug Induced Arrhythmia

❒ Primary VT/VF

❒ Unknown Etiology
Atrial Fibrillation or Flutter3120:

No;

Yes

Ventricular Tachycardia3130:

No,

Yes-VT, Non-Sustained;

Sinus Node Function3140:

Normal;

Abnormal

Cardiac Transplant3150:

No;

Yes

Yes-Monomorphic Sustained VT;

Non-Ischemic Dilated Cardiomyopathy3160:

No;

Ischemic Heart Disease3180:

No;

Yes-At Least One Epicardial Artery > 70%;

Previous MI3190:

No;

Yes-Within 40 days;

3200

Previous CABG

:

Yes-Within the past 3 months;

Yes-Polymorphic Sustained VT

Yes-3 to 9 months;

Yes-Greater than 9 months

Yes-Other Diagnostic Tests

Yes-Greater than 40 days;

Yes-Both Within 40 days/Greater than 40 days

3210

Previous PCI3220:

No;

Yes
→ if Yes, Date : ____/____/_______
Yes-Within the past 3 months;
Yes-Greater than 3 months

Previous Valvular Surgery3230:

No;

Yes

Permanent Pacemaker3240:

No;

Yes-Atrial Chamber;

Yes-Ventricular Chamber;

Yes-Dual Chamber;

Previous ICD3250:

No;

Yes-Single Chamber;

Yes-Dual Chamber;

Yes-Biventricular

No;

Yes-Biventricular

→ if Yes, Date3260: ____/____/_______
→ if Yes, Previous ICD Reason3280: (Check all that apply)

❒ Primary Prevention

❒ Syncope with Inducible VT

❒ Spontaneous Monomorphic Sustained VT

❒ Spontaneous Polymorphic Sustained VT

❒ Ventricular Fibrillation

❒ Cardiac Arrest/Arrhythmia-Etiology Unknown

❒ Syncope and High Risk Characteristics

❒ AFib

→ if Yes, Previous ICD Implant Site3290:
Cerebrovascular Disease3310:
No;

Yes

Chronic Lung Disease3320:

No;

Yes

Diabetes3330:

No;

Yes

Hypertension3340:

No;

Yes

Renal Failure Dialysis3350:

No;

Yes

Pectoral;

Abdominal

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-0967. The time required to complete
this information collection is estimated to average fifteen (15) minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

© 2005, American College of Cardiology Foundation

19-Feb-09

Page 1 of 3

ACC-NCDR® ICD Registry™v1.08 Data Collection Form
IMPLANT
E.

DIAGNOSTIC STUDIES:
Ejection Fraction Assessed3360:

No;

→ if Yes, EF%3370: _______%

Yes

3380

→ if Yes, EF Timeframe
:
0-1 month;
No;
Electrophysiology Study Done3390:

1-2 months;

2-3 months;

3-6 months;

6-12 months;

>12 months

2-3 months;

3-6 months;

6-12 months;

>12 months

Yes

→ if Yes, EPS Timeframe3400: 0-1 month;

1-2 months;

→ if Yes, EPS Findings3410: (Check all that apply. “No Arrhythmias Induced” is mutually exclusive.)
❒ No Arrhythmias Induced
❒ VT Induced
❒ Non-sustained VT
❒ Sustained Polymorphic
❒ Ventricular Flutter Induced
❒ Ventricular Fibrillation Induced
QRS Duration3420: _______(msec)
Normal;
AV Conduction3440:
(any)
Intraventricular Conduction3450:
Normal;
Abnormal-LBBB;

Abnormal-Left Posterior Fascicular Block;
Abnormal-Intraventricular Conduction Delay, Nonspecific;

Abnormal-Bifascicular Block (RBBB Plus LAF);
3460

Creatinine

F.

PR Interval Attainable3429
No;
Yes
→ if Yes, PR Interval3430: _______(msec)
st
Abnormal-1 Degree Heart Block Only;
Abnormal-Heart Block 2nd or 3rd Degree(not paced);
Paced

Abnormal-Left Anterior Fascicular Block;
Abnormal-RBBB;

Paced;

3470

:______ BUN

❒ Sustained Monomorphic
❒ Results Unattainable

:______

Sodium

3480

:______

Abnormal-Bifascicular Block (RBBB Plus LPF)
3485

BNP Drawn

No; Yes → if Yes, BNP3490:______

:

Systolic BP3500:______

ICD PROCEDURE:
ICD Indication3505:

Primary Prevention;

Secondary Prevention

Reason(s) for Re-implantation3506: (if Previous ICD3250 is Yes) (Check all that apply)
❒ End of Battery Life ❒ Device Upgrade
❒ Device Infection
❒ Device Malfunction
Multiple ICDs implanted during this admission3507:

No;

❒ Device Under Manufacturer Advisory/Recalled

Yes

→ If Yes, Reason(s) for device replacement during this admission3508: (Check all that apply)
❒ Device Upgrade
❒ Device Infection
❒ Device Malfunction
❒ Device Under Manufacturer Advisory/Recalled
Implant Operator’s UPIN3510: _____________________
Implant Operator’s NPI3515: _________________________
Implant Operator’s Last Name3530: ______________________
ICD Type3540:
Single Chamber;
Dual Chamber;
→ If Biventricular, LV Lead Implant Method3550:

First Name3520: __________________
Biventricular

Coronary Sinus;

Epicardial Lead;

Middle Name3525 _________________

Other

3565/3570

ICD Serial Number3566/3571

Manufacturer, Model Name, Model Number -or- ICD Device ID
Implant:

if Previous ICD3250 is Yes then complete Explant below
Explant:

G. ADVERSE EVENTS: (During or after the implant procedure until discharge.)
Adverse Events Exist3580:
Adverse Event3581

No;

Cardiac Arrestae001:
ae002

Drug Reaction

:
ae003

Cardiac Perforation

:

ae004

Cardiac Valve Injury

:

Conduction Blockae005:
Coronary Venous Dissect

ae006

:

ae007

Hematoma

:

Lead Dislodgement

ae008

:

ae009

Hemothorax

:

ae010

Pneumothorax

:
ae011

Peripheral Nerve Injury

ae012

Peripheral Embolus

Phlebitis - Superficial

:

ae013

:

:

❒
❒
❒
❒
❒
❒
❒
❒
❒
❒
❒
❒
❒

→ if Yes, then complete Adverse Events below.
Date3583
Adverse Event3581

Yes

____/____/____
____/____/____
____/____/____

Phlebitis - Deepae014:
ae015

TIA

:
ae016

CVA/Stroke

:

____/____/____

MI

____/____/____

Pericardial Tamponadeae018:

____/____/____
____/____/____

Date3583

ae0017

:
ae019

AV Fistula

:
ae020

Infection Related to Device

____/____/____
____/____/____

:

❒
❒
❒
❒
❒
❒
❒
❒
❒

____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____

____/____/____
____/____/____
____/____/____
____/____/____

© 2005, American College of Cardiology Foundation

19-Feb-09

Page 2 of 3

ACC-NCDR® ICD Registry™v1.08 Data Collection Form
IMPLANT
H.

DISCHARGE: (Complete this section at discharge)
CABG During this Admission3590: No;
3610

PCI During this Admission
3630

Vital Status

:

:

Alive;

→ if Yes, Date3600: _____/_____/_____

Yes

→ if Yes, Date3620: _____/_____/_____
Deceased-Cardiac Death;
Deceased-Non-Cardiac Death
No;

Yes

→ if Deceased, Date3640: _____/_____/_____
Discharge Date3650: _____/_____/_____

I.

→ if Deceased, Death in Lab3645:

No;

Yes

DISCHARGE MEDICATIONS: (Medications prescribed at discharge.)

if Vital Status3630 is Alive then complete Discharge Medications below.
Category
Medication Name3660
Prescribed 3665

Category

Medication Name3660

Prescribed3665

No Yes Con Blind

Ace Inhibitor

ACE-Inhibitor (any)m001

❒

❒

❒

❒

❒

❒

Disopyramidem003

❒
❒
❒
❒
❒
❒

❒
❒
❒
❒
❒
❒

❒
❒
❒
❒
❒
❒

❒
❒
❒
❒
❒
❒

❒
❒
❒

❒
❒
❒

❒
❒
❒

❒
❒
❒

❒

❒

❒

❒

Dofetilide

Flecainide

m005

Mexiletinem006
m007

Procainamide

Propafenonem008
m009

Quinidine

Sotalolm010
Other Anti. Arrhy.

m011

Antihypertensive Hydralazinem012

ARB

❒

Amiodaronem002
m004

Antiarrhythmic
Agent

❒

ARB (any)

m013

❒

❒

❒

No Yes Con Blind

Diltiazemm016
Other CCBm018

❒
❒
❒

❒
❒
❒

❒
❒
❒

❒
❒
❒

Coumadin

Coumadinm019

❒

❒

❒

❒

Digoxin

Digoxinm020

❒

❒

❒

❒

Diuretic

Diuretic (any)m021

❒

❒

❒

❒

Nitrate

Nitroglycerin SL, PRNm022

❒
❒

❒
❒

❒
❒

❒
❒

❒

❒

❒

❒

❒

❒

❒

❒

❒

❒

❒

❒

Calcium Channel
Blocker

Nitroglycerin Long Acting
Platelet Aggregation
Clopidogrelm024
Inhibitor
Ticlopidinem025

ASA

ASA

❒

❒

❒

❒

Beta Blocker

Beta-Blocker (any)m015

❒

❒

❒

❒

© 2005, American College of Cardiology Foundation

m023

❒
Statin

m014

Verapamil

m017

19-Feb-09

Statin (any)m026

Page 3 of 3