Cardiology (to be completed for each patient in eval)

    Demographics

    MaleFemale
    if Other Please specify

    Cardiovascular risk factors (if known)

    CurrentFormarNever
    YesNo
    YesNo
    YesNo
    Type 1Type 2Other
    YesNo

    Cardiac Symptoms

    If Other Please specify

    CAD-score

    YesNo
    If no Please specify

    Other non-invasive testing (if applicable)

    PosNegInconclusive
    PosNegInconclusive

    Diagnostic status

    Additional noninvasive testing deferredNon-significant CAD after cardiac noninvasive testingNo coronary atherosclerosis (no visible atherosclerosis by ICA)Non-significant CAD (FFR>0.80, instantaneous wave free ratio (iFR)>0.9, or 1-49% diameter stenosis by QCA)Significant CAD (FFR≤0.80, instantaneous wave free ratio (iFR) ≤0.89 or ≥50% diameter stenosis by QCA)

    Treatment

    YesNo

    Management Plan

    YesNo

    PCP (to be compeletd for each patient in eval)

    Demographics

    MaleFemale
    if Other Please specify

    Cardiovascular risk factors (if known)

    CurrentFormarNever
    YesNo
    YesNo
    YesNo
    Type 1Type 2Other
    YesNo

    Cardiac Symptoms

    If Other Please specify

    CAD-score

    YesNo
    If Other Please specify

    Other non-invasive testing (if applicable)

    PosNegInconclusive
    PosNegInconclusive

    Diagnostic status

    Additional noninvasive testing deferredNon-significant CAD after cardiac noninvasive testingNo coronary atherosclerosis (no visible atherosclerosis by ICA)Non-significant CAD (FFR>0.80, instantaneous wave free ratio (iFR)>0.9, or 1-49% diameter stenosis by QCA)Significant CAD (FFR≤0.80, instantaneous wave free ratio (iFR) ≤0.89 or ≥50% diameter stenosis by QCA)

    Treatment

    YesNo

    Management Plan

    YesNo
    YesNo
    YesNo
    LabsEKGStress EKGMedical HistoryCalcium ScoreOther

    To be completed once at the end of the evaluation by cardiology or PCP office

    Feedback on CPT III code 0716T

    Clinic Noninvasive Diagnostic Workflow:

    yesno
    yesNo

    Any other feedback for improvement?