Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for December of 2022. This case scenario is focused on coding CHADS-VASC-CHF sequence number 4005. Per our documentation, Mr. Edwards is admitted for an AFib ablation procedure. His documented past medical history includes persistent AFib, ischemic stroke, and hypertension. A diagnosis or history of CHF is not included in the patient's history and physical or pre-procedure office visit assessment. However, we do have documentation of Mr. Edwards taking Lasix on a daily basis and a documented NYHA Class of 2. Our question is, when capturing the patient's CHADS-VASC risk score based on the documentation provided in the patient's medication regimen, how will sequence 4005-CHF be coded? Number one, no. Or number two, yes. Please review the documentation in question to determine the best answer. The answer is number two, yes. Based on the coding instructions, CHADS-VASC-CHF is coded to indicate if the patient has been diagnosed with heart failure. The target value for this sequence is any occurrence between 30 days prior to the procedure, meaning that documentation used to code this element must be within 30 days prior to the start of the procedure. For the purpose of the AFib ablation registry, this element can also be coded if the patient is being medically treated for heart failure, as in this case, with a dose of daily Lasix. Or documentation of the New York Heart Association classification of 2, 3, or 4. This can also be used to code yes to CHADS-VASC-CHF. Based on the documentation of the patient's daily medication regimen, including Lasix, sequence 4005 can be coded as yes. Our bonus question uses the same documentation, except this time there is no documentation of Lasix being taken daily. However, we still have the documentation of a New York Heart Association class 2. How will sequence 4005-CHF be coded? Number one, no. Or number two, yes. The answer is number two, yes. Even though there is no documentation of a diagnosis of heart failure or mention of medical treatment, a documented NYHA class of 2, 3, or 4 can be used to code yes to sequence 4005. The CHADS-VASC elements can be coded with these options. Number one, provider documented CHADS-2-VASC assessment performed and heart failure was included. Number two, patient has been diagnosed with or had an episode of heart failure within 30 days prior to the procedure. Number three, a chronic or new diagnosis documented within 30 days prior to the procedure. Number four, patient medically treated for CHF with medications such as furosemide may be coded yes as the patient's CHF is currently being treated. Or number five, documentation of NYHA class 2, 3, or 4 can be used to code CHADS-2-VASC-CHF as yes, as this is a functional evaluation regarding the patient's limitation in ADL as a result of their heart failure. Thank you for reviewing the AFib Ablation Registry Monthly Case Scenario for December of 2022. For more information, please visit www.afib.nlm.nih.gov. Thank you.

AFib Ablation Registry

CHADS-VASC-CHF

coding

CHF

Lasix