February 2021

Documentation and Coding Series: Atrial Fibrillation

In our annual Blue Review readership survey, many of you asked for more articles on coding. In response, our Coding Compliance department has identified resources to help providers accurately code and document patient conditions. This month we are featuring documentation and coding information on atrial fibrillation and diabetes mellitus. Additional articles in the series will run throughout the year. Let us know what you think by emailing our editorial staff.

High quality documentation and complete, accurate coding may help capture our members’ health status and promote continuity of care. Below are resources for coding and documenting atrial fibrillation (AF). This information is from the ICD-10-CM Official Guidelines for Coding and Reporting and the resources listed below.

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• In coding, history of indicates a condition is no longer active.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 preventive exam as an opportunity to capture all conditions impacting patient care.

For more resources, see:

• 2021 ICD-10-CM (Chapter 9: Diseases of the Circulatory System)
• AHA Coding Clinic, Q2, Q4 2019
• Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance
• Blue Cross and Blue Shield of Illinois (BCBSIL) Medicare Advantage Annual Wellness Visit Guide

The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.