Atrial Fibrillation

High quality documentation and complete, accurate coding can help capture our members' health status and promote continuity of care. Below are tips for documenting and coding atrial fibrillation (AF). This guidance is from the ICD-10-CM Official Guidelines for Coding and Reporting  and industry-approved sources.

Codes for AF Types

According to ICD-10-CM guidelines,these four unique codes describe the types of AF:

• Persistent AF (I48.11) describes AF that does not terminate within seven days, or that requires repeat pharmacological or electrical cardioversion.
• Permanent AF (I48.21) is persistent or longstanding persistent AF where cardioversion cannot or will not be performed, or is not indicated.
• Chronic AF, unspecified (I48.20) may refer to any persistent, longstanding persistent or permanent AF.
• Chronic persistent AF has no widely accepted clinical definition or meaning. Code I48.19, Other persistent atrial fibrillation, should be assigned.

Active AF vs. "History of" AF

• In coding, "history of" indicates a condition is no longer active.
• Document in the note any current associated physical exam findings (such as irregular heart rhythm or increased heart rate) and related diagnostic testing results.
• Only one code may be assigned for a specific type of AF. The type of AF (paroxysmal, persistent, permanent or history of) should be documented consistently throughout the note to avoid unspecified codes that don't fully define the member's condition.

Best Practices

• Include patient demographics, such as name and date of birth, and date of service in all progress notes.
• Document legibly, clearly and concisely.
• Ensure documents are signed and dated by a credentialed provider.
• Document each diagnosis as having been monitored, evaluated, assessed and/or treated on the date of service.
• Note complications with an appropriate treatment plan.
• Take advantage of the Annual Health Assessment (AHA) or other yearly preventative exam as an opportunity to capture all conditions impacting member care.

Coding Example

Progress Note: Assessment: Atrial fibrillation, stable and controlled with digoxin.

Plan: Continue digoxin for AF and follow up in three months.

ICD-10: I48.91 (If supported by documentation, a more specific code than 148.91 should be used.)

For more details, see:

• 2021 ICD-10-CM  (Chapter 9: Diseases of the Circulatory System)
• AHA Coding Clinic, Q2, Q4 2019
• Centros de servicios del Programa Medicare y del Programa Medicaid Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance  
• BCBSNM Medicare Advantage Annual Wellness Visit Guide 

Questions? Contact your BCBSNM Network Representative.

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