Hello, everyone, and welcome back to our bimonthly case scenario. For this case scenario, we will resume our CHADS-VASc series by addressing sequence number 4020, hypertension. Mr. Smith is admitted for an AFib ablation procedure. The patient's past history includes longstanding AFib, several antiarrhythmics trial to which the patient is intolerant, ischemic stroke, and diabetes. Diagnosis or history of hypertension is not included in the patient's history and physical. The patient takes lisinopril 10 milligrams PO daily and took the medication on the day of the procedure. When capturing the patient's CHADS-VASc risk score based on the documentation provided, how will sequence number 4020, CHADS-VASc hypertension, be coded? Number one, no, or number two, yes. Please take a moment to review the documentation and question before making your final answer. And the answer is number two, yes. Based on the coding instructions, the CHADS-VASc hypertension is coded to indicate if the patient has been diagnosed with hypertension. The target value for the sequence is any occurrence between 30 days prior to the procedure. Any documentation used to code this element must be used within 30 days prior to the start of the procedure. For the purposes of the LAAO registry, even without a documented diagnosis of hypertension, this element can also be coded if the patient is on current antihypertensive pharmacologic treatment, as with their daily lisinopril. Further rationale for sequence number 4020, based on the documentation of the patient taking lisinopril as part of their daily regimen, sequence 4020 can be coded as yes. Some additional information. This CHADS-VASc element can be coded with these options. Number one, the provider documented CHADS-VASc assessment performed and hypertension was included. Number two, a documented diagnosis or active history of hypertension. Number three, the patient is on antihypertensive pharmacologic therapy as part of their daily medication regimen. Number four, documented resting systolic blood pressure greater than 140 or diastolic blood pressure greater than 90 on at least two occasions within 30 days from the start of the procedure. We thank you for taking the time to review our latest case scenario. We will continue with this series on CHADS-VASc elements in December.

coding

sequence number 4015

CHADS-VASC series

atrial fibrillation

congestive heart failure