Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for October of 2022. This case scenario is focused on coding haspled alcohol in sequence number 4105. Mr. Garcia was admitted for an AFib ablation procedure after having a long history of symptoms from AFib. When coding the ablation procedure into the registry, the following documentation was found in the patient's history and physical from the provider's office. A provider documented haspled score of 4 and the conditions of hypertension, stroke, alcohol use and anti-platelets being part of the patient's daily regimen used as the conditions to award the points to the risk score. History of CAD with a past PCI and long-standing persistent AFib. We also find documentation from the pre-procedure area, history and physical gathered by the nurse that Mr. Garcia uses alcohol daily and has a glass of whiskey and beer every evening. Based on the documentation from both assessments, office and pre-procedure, how will sequence 4105 be coded? Number one, no. Or number two, yes. 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, yes. Based on the haspled definition, alcohol excess is defined as consuming eight or more units of alcohol a week. The target value for this sequence is any occurrence between 30 days prior to the procedure, meaning the documentation used to code this element must be within 30 days prior to the start of the procedure. In this case, the provider personally documented their own haspled assessment of the patient with the target value and listed alcohol as a condition to award a point in the risk score, which means haspled alcohol can be automatically coded as yes. Based on the haspled definition, alcohol excess is defined as consuming eight or more units of alcohol a week. How do we define eight units? Charts like this one seen on the slide are readily available by searching alcohol units in the internet browser of choice. We can see that a shot of whiskey, which is almost an ounce, equals one unit, and a beer equals two or three units, depending on the size. Based on this chart, Mr. Garcia was consuming at least 21 units of alcohol per week. This haspled element can be coded with these options. A provider documented haspled assessment with alcohol use or excess documented as a condition used to award the patient a point in the assessment. In this case, we do not have to look for amount of alcohol consumed per week. Provider documentation is sufficient to code yes. If the provider did not document their own haspled assessment, we would use any documented history or diagnosis of alcohol excess or abuse within the target value or documentation of the amount of alcohol the patient consumes, equaling eight units or more. Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for October of 2022.

AFib Ablation Registry Monthly Case Scenario

coding

alcohol

sequence number 4105

haspled score