Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for March 2021. This month's case scenario is focused on Sequence 4065, Has Bled Abnormal Liver Function. Our patient, Mr. Perez, is admitted for an AFib ablation procedure. His past documented medical history includes long-standing persistent AFib, hypertension, cirrhosis of the liver, GI bleeding, which required admission and transfusions, ischemic stroke, congestive heart failure, past alcohol abuse, and his daily medication regimen includes Eliquis, Aspirin 81 mg, Lactulose, Lasix, Metoprolol, and Amiodarone. When capturing the patient's Has Bled risk score based on the documented patient's medical history, how will abnormal liver function be coded? Will it be coded yes or no? Let's review the documentation in question to determine the best answer. The answer is number one, yes. For the purpose of the AFib Ablation Registry, Sequence 4065 is to indicate if the patient has been diagnosed with an abnormal liver function. A diagnosis of cirrhosis, which is caused by chronic liver damage, or any other chronic liver condition causing an abnormal hepatic function can be used to code yes. Yes will be coded if the patient has been diagnosed or has an active history of abnormal liver 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 hepatic disease or condition. Chronic is defined as three months or greater. Or if no diagnosis of chronic hepatic disease is documented, biochemical evidence of significant hepatic derangement can be used. These include bilirubin more than two times the upper limit of normal in association with aspartate transaminase, alanine transaminase, and alkaline phosphatase levels, more than three times the upper limit of normal. Based on Mr. Perez's documented history, his HASB-led risk score will be coded as yes to hypertension, yes to abnormal liver function based on the active history of cirrhosis of the liver, yes to stroke, yes to bleeding as the GI bleeding history met criteria by requiring a blood transfusion and hospitalization, 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 March 2021.

AFib Ablation Registry Monthly Case Scenario

Sequence 4065

Mr. Perez

abnormal liver function

Has Bled risk score