Hello, everyone, and welcome to 2023. This year, we will focus on the CHA2DS2-VAS data elements since we have completed all of the HAS blood elements. We will start off the first case scenario of the year by focusing on sequence number 4005, CHA2DS2-VAS congestive heart failure. In this scenario, we will review a 75-year-old man who presents for a persistent nonvolvular atrial fibrillation with a history of congestive heart failure. The patient has had cardioversions twice in the past that were unsuccessful and an atrial fibrillation ablation that was also unsuccessful. The physician documents an episode of CHF within 15 days of the current procedure. The patient is chronically treated with a daily dose of an oral diuretic. Based on the information provided, how is sequence number 4005, CHA2DS2-VAS congestive heart failure, coded? Number one, no. Or number two, yes. Please take a moment to review the documentation in question before making a final answer. The answer is yes. For the purpose of the LAAO registry, in order to code yes to sequence 4005, CHA2DS2-VAS congestive heart failure, the patient has to have an active diagnosis or had a documented episode of heart failure within 30 days prior to the procedure. The physician may document a chronic or new diagnosis of CHF on pre-procedure assessments or pre-procedure H&P. If the patient is being medically treated with a CHF medication, as an example, furosemide, you may code yes as the patient's CHF is a chronic and current condition as they are still being medically treated. In this scenario, the patient had a documented admission for CHF 15 days prior to the admission and is chronically treated with a diuretic. For bonus question number one, we will continue to review the 75-year-old man who presents for a persistent non-valvular atrial fibrillation with a history of CHF. However, in this case, there is no physician documentation of recent CHF, but the physician has documented an NYHA, New York Heart Association, classification of 3. So how is sequence number 4005, CHA2DS2-VAS congestive heart failure, coded in this scenario? Please take a few moments to review the documentation before determining the best answer. The answer is yes. The abstractor may use a documented NYHA class of 2, 3, or 4 to code CHA2DS2-VASCHF as yes, as this is a functional evaluation regarding the patient's limitation in activities of daily living as a result of their heart failure. For bonus question number two, we will review the same patient, but in this case, there is no documentation of congestive heart failure within the last 30 days. In this scenario, the patient presents with shortness of breath with any exertion, has rails on auscultation, and complains of fatigue. So with this version of the documentation, how is sequence number 4005 coded? We'll give you again a few moments to review the documentation before determining the best answer. In this scenario, the answer is no. Per the data dictionary in the notes section for sequence 4005, it states that the diagnosis of heart failure must be specifically documented in the medical record and is not coded by the abstractor based on patient symptoms alone. To bring this case scenario to a close, we have provided a synopsis of the criteria documentation that can be used to code yes in sequence 4005. We hope that these points will aid you in making decisions in coding this data element. These CHA2DS2-VASCHF elements can be coded with the following options. Under documented, CHA2DS2-VASCHF assessment performed and heart failure was included. The patient has been diagnosed with or had a documented episode of heart failure within 30 days prior to the procedure. A chronic or new diagnosis of CHF is documented within 30 days prior to the procedure. A patient is being medically treated for CHF with medications such as furosemide may be coded as yes as the patient's CHF is currently being treated. A documented NYHA class of 2, 3, or 4 can be used to code CHA2DS2-VASCHF as yes because this is a functional evaluation regarding the patient's limitation of ADLs as a result of their heart failure. We thank you for taking the time to review our latest case scenario. We will continue with this series on CHA2DS2-VASCHF elements in April.

coding criteria

sequence number 4005

CHA2DS2-VAS congestive heart failure data element

active diagnosis

documented episode