Thank you for viewing the AFib Ablation Registry Monthly Case Scenario for February of 2023. This case scenario will be focused on coding CHADS-VASC hypertension, sequence number 4020. We have documentation of Mr. Smith being admitted for an AFib ablation procedure. Mr. Smith's documented past medical history includes longstanding persistent AFib, for which several antiarrhythmics have been trialed, but the patient was intolerant, ischemic stroke, and diabetes. A diagnosis or history of hypertension is not included in the patient's history and physical or pre-procedure office visit assessment. However, we do have documentation of Mr. Smith taking lisinopril 10 milligrams on a daily basis. Our question, when capturing the patient's CHADS-VASC risk score based on the documentation provided and the patient's medication regimen, how will sequence 4020 CHADS-VASC hypertension be coded? Number one, no, or number two, yes. Please take a moment to review the documentation in question to determine the best answer. And the answer is number two, yes. Based on the coding instructions, CHADS-VASC hypertension is coded to indicate if the patient has been diagnosed with hypertension. The target value for this sequence is any occurrence between 30 days prior to the procedure, meaning that any documentation, medication list, or assessment used to code this element must be within 30 days prior to the start of the procedure. For the purpose of the AFib Ablation Registry, even without a documented diagnosis of hypertension, as stated in the data dictionary, this element can also be coded if the patient is on current antihypertensive pharmacologic treatment, as in this case with daily lisinopril. Based on the documentation of the patient's daily medication regimen, including lisinopril, sequence 4020 can be coded as yes. This CHADS-VASC element can be coded with the following options. Number one, provider documented CHADS-VASC assessment performed and hypertension was included as a condition. Number two, documented diagnosis or active history of hypertension. Number three, the patient on antihypertensive pharmacologic therapy as part of their daily medication regimen. Or number four, documented resting systolic blood pressure higher than 140 millimeters of mercury or diastolic blood pressure higher than 90 millimeters of mercury on at least two occasions within 30 days from the start of the procedure. Thank you for reviewing the AFib Ablation Registry monthly case scenario for February of 2023.

coding CHADS-VASC hypertension

patient undergoing AFib ablation procedure

Mr. Smith

documented medical history

longstanding persistent AFib