0423 - Sequence # 4025 | CHADS-VASc - Diabetes Mellitus-0423 - Sequence # 4025

Video Transcription

Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for April of 2023. The case scenario will be focused on coding CHADS-VASC diabetes mellitus, sequence number  4025. We have documentation of Mrs. Perez being admitted for an AFib ablation procedure, which was performed during pulmonary vein isolation using cryoablation.  Mrs. Lopez documented past medical history includes paroxysmal atrial fibrillation, for which she takes Sotalol daily, high cholesterol, and hypertension.  When capturing the patient's CHADS-VASC risk score based on the documentation provided, how will sequence 4025 CHADS-VASC diabetes mellitus be coded?  Number one, no, or number two, yes. Please take a few moments to review the documentation and question to determine the best answer.  The answer is number two, yes. Based on the coding instructions, CHADS-VASC diabetes mellitus is coded to indicate if the patient has been diagnosed with diabetes.  The target value for this sequence is any occurrence between 30 days prior to the procedure, meaning that any documentation, medication list, lab values, 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, in this case, there is documentation within  30 days from the start of the procedure of diabetes being part of this patient's history and physical, as well as being part of the provider's CHADS-VASC assessment of the patient.  A documented history of diabetes in the pre-procedure H&P, as well as the provider including diabetes  as a condition used in the patient's CHADS-VASC assessment is sufficient documentation to code yes to sequence 4025.  This CHADS-VASC element can be coded having any of these options available, provider documentation  of the CHADS-VASC assessment performed and diabetes was included as a condition, documented  diagnosis or active history of diabetes, the patient on an oral hypoglycemic agent or insulin as part of their daily medication regimen, or a documented fasting plasma glucose level  greater than 7.0 within 30 days from the start of the procedure. Thank you for reviewing the AFib ablation registry monthly case scenario for April 2023.

Video Summary

In the video, the focus is on coding CHADS-VASC diabetes mellitus, sequence number 4025. Mrs. Perez is admitted for an AFib ablation procedure and has a past medical history of paroxysmal atrial fibrillation, high cholesterol, hypertension, and takes Sotalol daily. CHADS-VASC diabetes mellitus is coded by considering any occurrence within 30 days prior to the procedure. In this case, there is documentation within the timeframe indicating diabetes as part of the patient's history and physical, as well as being included in the provider's CHADS-VASC assessment. This is considered sufficient documentation to code yes to sequence 4025. Various options are available to code this element, including provider documentation of the CHADS-VASC assessment with diabetes, documented diagnosis or active history of diabetes, patient taking oral hypoglycemic agent or insulin, or documented fasting plasma glucose level greater than 7.0 within 30 days prior to the procedure.

Keywords

coding CHADS-VASC diabetes mellitus

sequence number 4025

AFib ablation procedure

paroxysmal atrial fibrillation

diabetes