Welcome back to our bi-monthly case scenario for the LAAO registry. For this case scenario, we will resume our CHADS FAST series by addressing sequence number 4025, diabetes mellitus. In this scenario, Mr. Hernandez, a 77-year-old male, is admitted for an LAAO procedure. His past medical history includes a long-standing history of non-valvular atrial fibrillation with a rapid ventricular rate necessitating frequent admissions for chemical and electrical cardioversion. He has a history of high cholesterol, hypertension, and diabetes documented in the History and Physical and included in the provider's CHADS FAST assessment. There is no fasting glucose documented, and Mr. Hernandez is not on insulin nor diabetic medications based on the medications documented. When capturing the patient's CHADS FAST risk score based on the documentation provided, how will sequence number 4025, CHADS FAST diabetes mellitus, be coded? No or Yes? Please take a moment to review the documentation and question before making a final answer. The answer is sequence number 4025 would be coded as yes, and the rationale is this. Based on the coding instructions, Chad's vast diabetes mellitus is coded to indicate if the patient has been diagnosed with diabetes. The target value for this sequence is any occurrence between 30 days prior to the procedure. Any documentation used to code this element must be within 30 days prior to the start of the procedure. In this case, there is documentation within 30 days from the start of the procedure of diabetes being part of the patient's history and physical, as well as being part of the provider's Chad's VASC assessment of the patient. Based on the documentation of the patient having a history of diabetes in the pre-procedure history and physical, as well as the provider including diabetes as a condition used in the patient's Chad's VASC assessment is sufficient documentation to code yes to sequence 4025. Additional information that may aid in coding this data element. The Chad's VASC element can be coded with these options. Provider documented Chad's VASC assessment performed and diabetes mellitus was included. Documented diagnosis or active history of diabetes mellitus. Patient was on oral hypoglycemic agent or insulin as part of a daily medication regimen. A documented fasting plasma glucose level greater than or equal to 7.0 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 the series on Chad's VASC elements in February of 2024.

coding

sequence number 4015

CHADS-VASC series

left ventricular dysfunction

LVEF value

coding sequence number 4025

diabetes mellitus

LAAO procedure

non-valvular atrial fibrillation

CHADS VASC assessment