Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for February 2021. This month's case scenario is focused on Sequence 4060, Has Bled Abnormal Renal Function. Our patient, Mr. Rogers, was admitted for an AFib ablation procedure and has a documented past medical history which includes persistent AFib, stage 3 chronic kidney disease, ischemic stroke, uncontrolled hypertension, GI bleeding episode while on Warfarin which required admission and a blood transfusion, and his medication daily regimen includes aspirin 81 mg and Xarelto. Mr. Rogers' provider did not document a has bled assessment, therefore the abstractor will use the documented patient history to code the assessment. When capturing the patient's has bled risk score based on the documentation provided and the patient's documented history, how will abnormal renal function be coded? Will it be coded yes or no? Please take a moment to review the documentation and question to determine the best answer. The answer is number one, yes. For the purpose of the AFib Ablation Registry, Sequence 4060 is to indicate if the patient has been diagnosed with an abnormal renal function. A diagnosis of chronic kidney disease or injury are abnormal renal functions. Yes will be coded if the patient has been diagnosed or has an active history of abnormal renal function that has been documented between 30 days pre-procedure and the actual procedure. Documentation that can be used to code this element are new diagnosis or history of chronic kidney disease or any chronic kidney condition, recipient of at least one kidney transplant, chronic dialysis in the past or a dialysis treatment in the week prior to admission, or if there is no documentation of a chronic condition as listed above, a serum creatinine of 2.6 mg per deciliter or higher can be used to code yes. Based on Mr. Rogers' documented history, his has bled risk score will be coded as yes to hypertension, yes to abnormal renal function, yes to stroke, yes to bleeding as the bleeding episode met criteria by requiring a blood transfusion, and yes to antiplatelet as the patient takes aspirin 81 mg as part of his daily regimen. Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for February 2021.

AFib Ablation Registry

persistent AFib

chronic kidney disease

ischemic stroke

uncontrolled hypertension