Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for November of 2021. This month's case scenario is focused on coding a pericardial effusion complication in intra- or post-procedure events. A 65-year-old patient was admitted for a planned endocardial AFib ablation procedure, which was planned to be performed using pulmonary vein isolation as the ablation strategy. During the procedure and transeptal puncture, the patient suffered a cardiac perforation. The patient exhibited symptoms of tamponade, which prompted an emergency pericardiocentesis to be performed, from which one liter of bloody fluid was aspirated. The patient's symptoms continued to deteriorate, and the patient was transferred for an emergent cardiac surgery. Based on the documentation found, when coding procedure information, what intra- or post-procedure events will be coded in Section H? Will it be coded as pericardial effusion resulting in cardiac tamponade, sequence 9060, pericardial effusion requiring intervention, sequence number 9065, cardiac surgery, sequence 9070, or all of the listed events 1, 2, and 3? Please review the documentation and question to determine the best answer. We will give you a few seconds to review. And the answer is number 4, all of the above responses 1, 2, and 3. Based on the documentation provided, we would code all of the events listed as the criteria for all was met. Pericardial effusion resulting in cardiac tamponade, sequence 9060, will be coded as there is documentation of tamponade resulting from the pericardial effusion. Pericardial effusion requiring intervention, sequence 9065, will be coded as the pericardial effusion required in emergent pericardiocentesis. And cardiac surgery unplanned emergent, sequence 9070, will be coded as the patient required an unplanned emergent cardiac surgery. Some additional information. Hemorrhage, non-access site, sequence 9080, will also be coded as an event if associated with any of the criteria listed. Hemoglobin drop of greater than or equal to 3 grams per deciliter, transfusion of whole blood or packed red blood cells, and procedure intervention surgery at the bleeding site to reverse stop or correct the bleeding. Based on the documentation available and the progression of the complication during the procedure, hemorrhage, non-access site, will be coded as an event since it required a procedural intervention surgery at the bleeding site to reverse stop or correct the bleeding, meeting at least one of the criteria listed. Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for November of 2021.

AFib Ablation Registry

complications

cardiac perforation

tamponade

pericardiocentesis