Hello, everyone, and welcome back to our CHADS-VASc series. Today we will focus on sequence 4010, CHADS-VASc New York Heart Association functional classification, as there has been clarification of coding this data element. In this scenario, we will use the same patient documentation from our last case scenario in February, a 75-year-old man who presents for persistent non-valvular atrial fibrillation with history of congestive heart failure. The patient has had two cardioversions in the past that were unsuccessful and an atrial fibrillation ablation that was unsuccessful. The physician has documentation of hospital admission for CHF within 15 days of the current procedure. The patient is chronically treated with a daily dose of a loop diuretic. There is no physician documentation of functional classification to enable coding. His symptoms on admission are recurrent exertional shortness of breath, walking across a room, and his respiratory rate at rest is 22. Based on the information that was provided, how is sequence 4010 CHADS-VASc New York Heart Association functional classification coded in this scenario? Is it class 1, class 2, class 3, class 4, or left blank? Please take a moment to review the documentation and question before making a final answer. The answer is number 5. After attempt clarification with the provider, and if that is not possible, then leave blank. When coding sequence number 4010 in version 1.4, there should be documentation by the physician to enable coding. Per the notes section of the coding instructions in the data dictionary, the NYHA class should no longer be coded by the abstractor based on patient symptoms. This represents a change in coding advice from version 1.3. When the physician has failed to provide documentation that would enable coding the New York Heart Association functional classification in sequence 4010, we first recommend clarification from the physician and an amendment to the medical record per the policy of your facility to support coding. If clarification is unavailable, please leave sequence 4010 blank as there is nothing to support coding. After consulting with the registry's product manager, it was confirmed that sequence 4010 NYHA functional classification will be coded as stated in the data dictionary, only with specific documentation found in the medical record and not upon symptoms. The FAQs have been updated to reflect the above statement. Sequence 4010 NYHA functional classification does not have a target value of 30 days prior to the procedure, as does sequence 4005 CHADS-VASC-CHF. Sequence 4010 has a target value of the highest value on the first procedure in the admission. When coding the patient's New York Heart Association class, if no current documentation is found and the patient's NYHA class has not changed since last documented, you may use the NYHA class documented to code. We thank you for taking the time to review our latest case scenario. We will continue with this series on CHADS-VASC elements in June.

CHADS-VASc

New York Heart Association

functional classification

coding

physician documentation