Welcome to the STS-ACC TVT Registry Case Scenario, where we will review coding aortic valve regurgitation in sequence 13.526, post-procedure aortic valve regurgitation, and sequence 13.527, follow-up aortic valve regurgitation. An 84-year-old patient with a diagnosis of aortic stenosis was admitted for a TAVR procedure. The TAVR was performed successfully, and the patient was transferred to the post-procedure care unit. There was no physician documentation of aortic regurgitation. However, the echo performed before discharge stated mild paravalvular leak, and the 30-day follow-up echo stated trace trivial paravalvular leak. Our question is, how is sequence number 13.526 post-procedure aortic regurgitation coded? Number one, none. Number two, trace trivial. Number three, mild. Number four, moderate. Or number five, severe. Please take a few moments to review the documentation before making a final selection. And the answer is number three, mild. Overall, aortic regurgitation post-TAVR procedure is coded on physician documentation first. When physician documentation is absent, overall aortic regurgitation is typically assessed by a combination of both paravalvular severity and central severity. Therefore, sequence number 13.526 post-procedure aortic valve regurgitation is coded to the highest value of the documentation in sequence 14.503, paravalvular aortic regurgitation, and or sequence 14.487, central aortic regurgitation, from the post-procedure echocardiogram, which in this scenario is mild. This is supported in FAQ ID 25309, which is located under our Resources tab. In our follow-up bonus question, using the exact same scenario, how is sequence number 13.527 follow-up aortic regurgitation coded? Number one, none. Two, trace trivial. Three, mild. Four, moderate. Or five, severe. Please take a few moments to review the documentation before making your final selection. And the answer is number two, trace trivial. Overall, aortic regurgitation post-TAVR procedure is coded on physician documentation first. When physician documentation is absent, overall aortic regurgitation is typically assessed by a combination of both paravalvular severity and central severity. Therefore, sequence number 13.527 follow-up aortic valve regurgitation is coded to the highest value of the documentation in sequence number 14.504, paravalvular aortic regurgitation, and or sequence number 14.500, central aortic regurgitation from the follow-up echocardiogram, which in this scenario is trace trivial. While, as in this scenario, the follow-up echo reported trace trivial paravalvular leak regurgitation, the note in the data dictionary further clarifies that if trace or trivial is documented as the severity of paravalvular aortic regurgitation on the follow-up echocardiogram, to please code none as there is no trace trivial selection. Thank you for viewing the TVT Registry Case Scenario.

coding

aortic valve regurgitation

13.526

13.527

TAVR procedure