Coding Tip: Atrial Fibrillation
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
Atrial Fibrillation – What is it and how do you code it?
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation:
- I48.91 is used to report atrial fibrillation when no further specificity is available
- I48.2 is used to report atrial fibrillation when specified as chronic or permanent (Will be expanded 10/1/19)
- I48.0 is used to report atrial fibrillation when specified as paroxysmal
- I48.1 is used to report atrial fibrillation when specified as persistent (Will be expanded 10/1/19)
What is atrial fibrillation?
Atrial fibrillation is an irregular heartbeat or arrhythmia sometimes called a quivering heart. This arrhythmia can cause a patient to develop blood clots, have a stroke, heart failure or other conditions. The heart rate is most often rapid and causes poor blood flow. When a patient is in atrial fibrillation, the upper chambers of the heart (atria) are beating differently than the lower chambers (ventricles). When this occurs, the irregular rhythm/heartbeat, prohibits the atria from contracting/relaxing and causes ineffectual filling and emptying of the ventricles. This is referred to often as a chaotic dysrhythmia.
The causes of atrial fibrillation is oftentimes unknown, but can be the result of damage to the heart’s electrical system caused by conditions such as uncontrolled hypertension and coronary artery disease. Atrial fibrillation can develop in any person including children but the risk is higher in patients of advanced age, have hypertension, have underlying heart disease, binge drinking of alcoholic beverages, family history, sleep apnea sufferers, athletes, patients with thyroid disease, diabetes and asthma are some of the more common disease that put a patient at higher risk for developing atrial fibrillation.
Controlling the disease that causes the erratic heartbeat is a must, as well as treating the arrhythmia. Sometimes treating and controlling the underlying cause will make the atrial fibrillation go away. If this does not help the erratic rhythm, then the patient may require treatment with beta blockers and calcium channel blockers to help slow the heart rate. The rhythm should be restored to a normal rhythm to reduce the high heart rate. Patients are often placed on a blood thinner to help prevent blood clot and stroke in addition to the rate and rhythm controller medication. The rhythm should be restored to a normal rhythm to reduce the high heart rate. There are other treatments available such as electrical cardioversion, radiofrequency/catheter ablation, pacemakers and an open heart maze procedure for the atrial fibrillation that does not correct on its own or does not respond to the medications.
How to code multiple documented types of atrial fibrillation?
The most recent coding advice has addressed how to report the appropriate code for the atrial fibrillation when more than one type is documented. Per this advice, if the physician diagnoses the patient with chronic persistent atrial fibrillation only the code I48.1 (persistent atrial fibrillation) is reported. The term chronic is a nonspecific term that could also be used to describe the other types of specified atrial fibrillation. Since I48.1 is a more specific code this is the one that should be reported. Even though the Alphabetic Index within ICD-10-CM has listed the different types of atrial fibrillation at the same indention level, only one code is reported. The most specific term should be reported.
Atrial Fibrillation Coding Tips:
- Atrial fibrillation is still reported in patients that are not currently experiencing the erratic rhythm as long as the patient is requiring ongoing medication to help control the rate
- Atrial fibrillation is very common in postoperative patients and should be verified as a complication before coding as such
- When multiple types of atrial fibrillation are documented in the record select the most specific type
There are other examples of how to code atrial fibrillation when multiple types are documented in the latest issue of Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019: Page 3.
mayoclinic.org/diseases-conditions/atrial-fibrillation/symptoms-causes/syc-20350624Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019: Page 3
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2018: Page 6
Coding Clinic, Fourth Quarter 2013 Page: 11 & 98
Coding Clinic, Third Quarter 1995 Page: 8
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
In Part 8, we focused on identifying if a discectomy was performed, and if so, if it was a partial or a total discectomy. In Part 9, we are going to focus on identifying if a decompression was performed, and if so, was it of the spinal cord, spinal nerves or both?
In Part 7, we focused on identifying any instrumentation that may be used during a spinal fusion. In Part 8, we are going to focus on identifying if a discectomy is performed and if this is an excision or a resection of the disc.
In Part 6, we focused on identifying the type of bone graft product used for the spinal fusion. In Part 7, we are going to focus on identifying any instrumentation or device used.
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
We interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them. This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
We interviewed our most productive coders and reviewers, asking them what steps they take to find a rhythm that works for them. This week, we talked with Valerie Abney, CDIP, RHIT, CCS, about the steps she takes to find her routine.
Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
Back in April, the Office of the Inspector General (OIG) published a report detailing its findings from a review of two groups of high-risk diagnosis codes, acute stroke and major depressive disorder. The objective was to determine whether selected diagnosis codes submitted to the Centers for Medicare and Medicaid Services for use in CMS’s risk adjustment program complied with Federal requirements.
There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?
Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?
In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?