Hello, everyone, and welcome back to our case scenario CHADS-VASC series. Today we will focus on sequence number 4015, CHADS-VASC, New York Heart Association, left ventricular dysfunction. This will be our third in this series. In this scenario, we will use some of the patient documentation from our last case scenario. A 75-year-old male presents for persistent non-valvular atrial fibrillation with a history of congestive heart failure and non-ischemic cardiomyopathy. There is no physician documentation of left ventricular dysfunction and no value reported for left ventricular ejection fraction on the echo. Based on the information provided, how is sequence number 4015, CHADS-VASC, New York Heart Association, LV dysfunction coded in this scenario? Number one, no, or number two, yes. Please take a moment to review the documentation in question before making a final answer. And the answer is number one, no. For the purpose of the LAAO registry, in order to code yes to sequence 4015, the patient's LVEF must be documented to be less than 40% or have a history or active diagnosis of LV dysfunction documented within 30 days of the procedure. Sequence number 4015 is not coded by the abstractor based on patient symptoms or a history of cardiomyopathy alone. In this scenario, we will maintain the documentation of persistent non-valvular atrial fibrillation and congestive heart failure by history. In this question, the physician has documented LV dysfunction and has provided an LVEF of 38% on an echo completed 10 days ago. The patient admission symptoms are unchanged. How is sequence number 4015 coded in this scenario? The answer is yes. In this scenario, there is documentation of LV dysfunction and an LVEF percentage to meet the data definition. For the registry, if a patient has a diagnosis of CHF with a documented EF less than 40%, please code yes. A bonus question. The physician has not documented left ventricular dysfunction, but there is an EF of 38% documented 36 days prior to the procedure. So how is sequence 4015 coded in this scenario? The answer is no. For the purpose of the LAAO registry, in order to code yes to sequence 4015, the patient's LVEF must be documented to be less than 40% or have a history or active diagnosis of LV that must be documented within 30 days of the procedure. Based on the information given, please code no to sequence 4015 as an LVEF or LV dysfunction diagnosis was not documented. When coding sequence number 4015, CHADS-VASC left ventricular dysfunction, the following may be used to facilitate coding. The provider has documented a CHADS-VASC assessment was performed and left ventricular dysfunction was included in the score. Sequence 4015 may be coded as yes if there is an echocardiogram report that shows a left ventricular ejection fraction less than 40% in the last 30 days prior to the procedure. Sequence number 4015 cannot use an LVEF documented greater than 30 days prior to the procedure. We thank you for taking the time to review this case scenario. We will continue with the series on CHADS-VASC elements in August.

coding

sequence number 4015

CHADS-VASC series

left ventricular dysfunction

LVEF value