Atrial Fibrillation (AF)

Paroxysmal AF Definition: Episodes terminate either spontaneously or with treatment within 7 days; may recur

Persistent AF Definition: AF is continuous and lasts > 7 days, fails to terminate spontaneously

Long-standing Persistent AF Definition: Continuous AF lasts > 12 months (due to either failure of initiation of pharmacological intervention or failure of cardioversion)

Permanent AF Definition: Rythm is unresponsive, so decision made not to peruse further treatments attempted to restore or maintain NSR

Diagnostic Criteria

Risk factors include the following:

• Advanced age, underlying heart/lung disease (valvular/structural/ischemic heart disease, CAD, asthma, COPD, OSA), endocrine disorders (diabetes/hyperthyroidism), smoker, increased alcohol consumption, illicit drug use, hyperlipidemia, hypertension, and congenital heart disease
• Patients may describe shortness of breath, general fatigue, nausea, dizziness, chest pain, rapid heart rate or lower extremity swelling
• ECG demonstrates narrow complex ‘irregularly irregular’ pattern without the presence of p-waves

Coding Considerations

Review pertinent Coding Clinics such as:

• AHA Coding Clinic, Second Quarter 2022, p. 17 Long-Term Use of Eliquis
• AHA Coding Clinic, Second Quarter 2021, p. 8 Persistent Atrial Fibrillation, Anticoagulant Therapy and Acquired versus Inherited Hypercoagulable State
• AHA Coding Clinic, Fourth Quarter 2019, p. 7 ICD-10-CM New/Revised Codes: Atrial Fibrillation
• AHA Coding Clinic, Second Quarter 2019, p. 3 Chronic Persistent Atrial Fibrillation
• AHA Coding Clinic, Second Quarter 2019 p. 3 Different Type of Atrial Fibrillation

Persistent atrial fibrillation (I48.1) has an Excludes1 note identifying permanent atrial fibrillation cannot also be captured.

Chronic atrial fibrillation, unspecified (I48.19) has an Excludes1 note identifying chronic persistent atrial fibrillation cannot also be captured.

ICD-10-CM identifies persistent atrial fibrillation as either longstanding persistent atrial fibrillation (I48.11) or other persistent atrial fibrillation (I48.19) which has inclusion terms of chronic persistent atrial fibrillation and persistent atrial fibrillation, NOS. Both I48.11 and I48.19 are designated with CC status.

ICD-10-CM identifies chronic atrial fibrillation as either chronic atrial fibrillation, unspecified (I48.20) or permanent atrial fibrillation (I48.21), both are designated with CC status.

Assign code I48.19, other persistent atrial fibrillation, for chronic persistent AF.

All atrial fibrillation codes map to an HCC for both Medicare Advantage and the Affordable Care Act (HHS) and can affect Risk Adjustment scores.

CDI Practice Considerations

• Atrial fibrillation is the most common type of cardiac arrhythmia, making it a common comorbidity. Review the record closely, querying when clinical indicators support the specific type of atrial fibrillation.
• Long-standing persistent, other persistent, chronic, and permanent are recognized as CC’s while unspecified and paroxysmal are not given CC status.
• Review for various body site locations for embolism as atrial fibrillation can lead to thrombus formation, which can dislodge, embolizing at various body locations, the most common being the brain (CVA).
• Right heart strain can lead to atrial fibrillation, review the record closely for clinical indicators supportive of a pulmonary embolism, querying when appropriate.
• Review for other common comorbidities, which include heart failure (CC if type specified as systolic/diastolic, and MCC when type specified with acuity of acute or acute on chronic) and complications associated with anticoagulation, such as hemorrhagic disorders due to intrinsic circulating anticoagulants (CC).
• Review MAR Summary’s and home med list carefully, as treatment in the form of rate control [beta-blockers (e.g. metoprolol), calcium-channel blockers (e.g. diltiazem/verapamil), digoxin etc.] and/or rhythm control [antiarrhythmic (e.g. amiodarone)] may provide clinical indicator support for the different types of atrial fibrillation, query as necessary.
• Note, only assign one code for the specific type of atrial fibrillation.
• Chronic atrial fibrillation, unspecified (I48.20) may refer to any persistent, longstanding persistent, or permanent atrial fibrillation. However, in clinical practice, use of one of the more specific descriptive terms is preferred over the use of the nonspecific term chronic AF.
• Review the facility’s approved abbreviation list as ‘AF’, could mean atrial fibrillation or atrial flutter, which map to different ICD-10 codes potentially impacting DRG assignment.
• If the patient is on CURRENT long-term coagulation therapy, code the atrial fibrillation as current. If the patient has a PMH of atrial fibrillation which has resolved and is no longer under treatment, do not code.

            > Example: patient has had previous cardioversion, ablation and/or MAZE procedure and is no longer on current                      medication for atrial fibrillation, the atrial fibrillation cannot be coded.

            > Example: patient has had previous cardioversion, ablation and/or MAZE procedure and remains and/or is                                  currently on medication for atrial fibrillation, the atrial fibrillation should be coded.

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