Coding Clinic Advice about Atrial Fibrillation Made My Heart Flutter

Original story posted on: July 1, 2019

The author shares her thoughts on atrial fibrillation in the AHA Q2 Coding Clinic.

I reviewed the Coding Clinic from Second Quarter and disagree with the reasoning for the first question regarding atrial fibrillation, although I do not have a problem with their solution. Fortunately, after October 2019, the advice will be nullified anyway. My objection, though, is that the explanation for the coding advice is not clinically sound.

The submitted question regarded a patient who was on antiarrhythmic drugs for atrial fibrillation and the provider documented, “Chronic persistent atrial fibrillation.” The question posed was, “should I48.1, persistent atrial fibrillation or I48.2, chronic atrial fibrillation be coded?” The answer was to use persistent atrial fibrillation because it is a more specific code.

I believe the answer revealed a lack of understanding of the clinical situation. Atrial fibrillation is a dysrhythmia which occurs when the sinus node is no longer sending out regular impulses for a rhythmic contraction of the heart muscle. It is caused by dysfunction of the heart’s electrical system, with risk factors such as advanced age, genetic predisposition, structural and valvular heart disease, hypertension, alcohol, lung and thyroid disease. The chaotic electrical signals cause a disordered, ineffective muscular movement of the atrium and unpredictable propulsion of the electrical signal. This causes the ventricles to contract at irregular intervals, usually rapidly unless a patient has medication on board to slow down the rate.

Sometimes it easily or spontaneously converts back to a normal sinus rhythm, usually within 48 hours. It is often recurrent. This is known as paroxysmal atrial fibrillation. Paroxysmal means comes and goes.

Sometimes it comes and persists until medical care coaxes the heart back into a normal rhythm with medication or electricity. It usually lasts a week or more. This is called persistent atrial fibrillation. If it lasts for a long time (i.e., more than 12 months), we call it longstanding persistent atrial fibrillation.

Since the “natural” tendency of atrial fibrillation is to cause a rapid heartbeat (i.e., atrial fibrillation with a rapid ventricular response), we use medication like beta blockers or calcium channel blockers to try to control the rate. In cases where the provider and patient have been unsuccessful at converting the atrial fibrillation, rate control may be the only solution. The point at which the patient and physician determine a conversion is no longer a feasible option and that rate control is the only course to take is the point at which longstanding persistent atrial fibrillation gets a change in name only to permanent atrial fibrillation.

“Chronic” and “permanent” atrial fibrillation are usually considered synonymous, but this is not nonspecific. My opinion is that both “chronic” and “paroxysmal” are unfortunate terms because they are descriptive and not discriminating. Persistent atrial fibrillation can recur just as paroxysmal can, and long-standing persistent atrial fibrillation can be considered a “chronic” condition.

In October, we will be getting new ICD-10-CM codes. Persistent will be subdivided into I48.11, longstanding persistent atrial fibrillation and I48.19, Other persistent (with the inclusion term, “chronic persistent atrial fibrillation”), and chronic are becoming I48.20, unspecified Chronic and I48.21, Permanent atrial fibrillation. The good news is that all of these will be comorbid conditions or complications, not only persistent, as it stands presently. The bad news is we have to wait until then for a precise and accurate way to code the verbiage, “chronic persistent atrial fibrillation.”

Until then, if Coding Clinic is advising us to use persistent atrial fibrillation for that documentation rather than querying the provider to see if they really meant chronic (permanent) or persistent, so be it! Just do it because they told you to, not because it makes clinical sense.

On another topic, last year, Laura Hayman and I brought up the topic of NAT on Talk Ten Tuesday. On page 12, Coding Clinic recommends the translation of the verbiage, “injury pattern highly suspicious for non-accidental trauma or NAT,” into the code for suspected child physical abuse, T76.12XA. I am delighted to see them make that ruling.

Programming Note:

Listen to Dr. Erica Remer live every Tuesday on Talk Ten Tuesday, 10-10:30 a.m. EST.

Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. She was a physician advisor of a large multi-hospital system for four years before transitioning to independent consulting in July 2016. Her passion is educating CDI specialists, coders, and healthcare providers with engaging, case-based presentations on documentation, CDI, and denials management topics. She has written numerous articles and serves as the co-host of Talk Ten Tuesdays, a weekly national podcast. Dr. Remer is a member of the ICD10monitor editorial board, the ACDIS Advisory Board, and the board of directors of the American College of Physician Advisors.

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