0720 - Sequence # 4565 & 4570 | (Cardiomyopathy & CM Type)-0720 - Sequence # 4565 & 4570

Video Transcription

Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for July 2020.  This month's case scenario is focused on sequence 4565, cardiomyopathy, and 4570, cardiomyopathy type.  We have documentation of a patient having a successful AFib ablation procedure. When the quality team is abstracting the procedure into the registry, this is the medical history  documented for the patient. The patient was diagnosed with persistent AFib, has an active diagnosis of hypertension,  for which the patient is on antihypertensives, TIA in 2005, CHF with an LVEF of 35%, cardiomyopathy,  however, the type of cardiomyopathy is not documented, and a prior MI with a coronary artery bypass graft surgery in 2013.  Based on the documentation available, we will code sequence 4565, cardiomyopathy as yes, however, since the type of cardiomyopathy is not documented, how would cardiomyopathy  type in sequence 4570 be coded? 1, non-ischemic, 2, ischemic, 3, restrictive, 4, hypertrophic, or 5, other.  Please review the documentation and question to determine the best answer. We will give you a few seconds to review.  The answer is number two, ischemic. If the type of cardiomyopathy is not documented and cannot be obtained from the provider,  which should be the first step to confirm the type of cardiomyopathy, the patient's past medical history can be used to code the type.  For example, in this case, if the patient has a history of prior MI, PCI, or CABG, ischemic can be coded as the type of cardiomyopathy.  Other examples can be a diagnosis of dilated cardiomyopathy can be coded as non-ischemic if no other history is documented.  A diagnosis of tachycardia-induced cardiomyopathy can be coded as non-ischemic. An unclassified cardiomyopathy or any cardiomyopathy not fitting into any other type can be coded  as other. Examples of these are LV non-compaction or stress-induced tachosubo. Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for July 2020.

Video Summary

The video discusses a case scenario regarding a patient who underwent a successful AFib ablation procedure. The patient has a medical history that includes a diagnosis of persistent AFib, hypertension, TIA, CHF with an LVEF of 35%, cardiomyopathy (without documented type), and a prior MI with a coronary artery bypass graft surgery. Based on the available documentation, the code for cardiomyopathy is "yes," but the type is unknown. The video suggests that if the type cannot be obtained from the provider, the patient's past medical history can be used to code it. In this case, an ischemic cardiomyopathy is coded due to the patient's history of prior MI and CABG. Other types of cardiomyopathy are also discussed and how they should be coded. No specific credits are mentioned in the video.

Keywords

AFib ablation procedure

persistent AFib

cardiomyopathy

prior MI

coding