0122 - Sequence # 7258 | Aortic Valvuloplasty Post Dilation Regurgitation-0122 - Sequence # 7258 | Aortic Valvuloplasty Post Dilation Regurgitation

Video Transcription

Welcome to the IMPACT Registry January 2022 case scenario, where we will discuss sequence number 7258, aortic valvuloplasty post-dilation regurgitation.  A 10-year-old male presents to the physician's office for a sports physical. The parents report that he is experiencing increasing fatigue with activity, dizziness,  and chest pressure. On auscultation, a heart murmur is noted. An echocardiogram is performed, and the results report a decreased ejection fraction, left  ventricular hypertrophy, and aortic valve stenosis. The patient is scheduled for a stress test, which is abnormal, along with ECG changes during the study.  And the patient undergoes an aortic valvuloplasty. Post-procedure, the physician documents successful treatment of stenotic valve with trivial regurgitation post-dilation.  Our question is, how is sequence number 7258 post-dilation regurgitation coded? Is it number one, none? Number two, one plus, mild? Number three, two plus, moderate?  Number four, three plus, moderately severe? Number five, four plus, severe? Or number six, leave blank?  Please take a moment to review the documentation and the question before making your selection.  And the answer is number six, leave blank. Trivial trace regurgitation is subjective in nature and does not meet the numerical  values or descriptive definitions found in the data dictionary. Because descriptive terms are subjective, neither the abstractor nor the registry should  determine the regurgitation level. None would not be selected when the post-dilation regurgitation is documented as trivial and or trace.  And mild, one plus, would not be selected when the post-dilation regurgitation is documented as trivial and or trace.  If the coder is unable to clarify with the physician for coding purposes, please leave this data field blank.  However, if this data field is consistently left blank, it will fill the DQR. Please continue to communicate to your clinicians that reporting, documenting in numerical values  to relay the value regurgitation best supports accurate data abstraction in the registry.  Thank you for reviewing the impact registry monthly case scenario for January of 2022, where we discussed sequence number 7258, aortic valvuloplasty post-dilation regurgitation.

Video Summary

In this video, the IMPACT Registry discusses a case scenario involving a 10-year-old patient who presents with symptoms of fatigue, dizziness, and chest pressure. The patient is diagnosed with aortic valve stenosis and undergoes an aortic valvuloplasty. Post-procedure, the physician documents successful treatment of the stenotic valve with trivial regurgitation. The question is how to code the regurgitation level, and the answer is to leave it blank because trivial trace regurgitation is subjective and does not have numerical values or descriptive definitions in the data dictionary. The video emphasizes the importance of accurate data abstraction in the registry and encourages communication with clinicians for better reporting and documentation. No credits were granted.

Keywords

IMPACT Registry

case scenario

10-year-old patient

aortic valve stenosis

aortic valvuloplasty