Documentation and Coding Guidance - Atrial Fibrillation

Feb. 01, 2021

High quality documentation and complete,accurate coding can help capture our members' health status and promotecontinuity of care. Below are resources for documenting and coding atrialfibrillation (AF). This information is from the ICD-10-CM Official Guidelines for Coding and Reporting and the sources listed below*.

ICD-10-CM AF Codes 

Paroxysmal AtrialFibrillation

I48.0

Persistent Atrial Fibrillation

I48.1x

Chronic Atrial Fibrillation

I48.2x

Typical Atrial Flutter

I48.3

Atypical Atrial Flutter

I48.4

Unspecified AtrialFibrillation

I48.91

Unspecified Atrial Flutter

I48.92

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 requiresrepeat pharmacological or electrical cardioversion.
  • Permanent AF (I48.21) is persistent or longstanding persistent AF where cardioversion cannot orwill not be performed, or is not indicated.
  • Chronic AF, unspecified (I48.20) may refer to any persistent, longstanding persistent orpermanent 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  • In coding, "history of" indicates a condition is no longer active.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 (suchas irregular heart rhythm or increased heart rate) and related diagnostictesting 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 documentedconsistently throughout the note to avoid unspecified codes that don't fullydefine the member's condition.

Best Practices

  • Include patient demographics, such as name and date of birth, and date ofservice 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, assessedand/or treated on the date of service.
  • Note complications with an appropriate treatment plan.
  • Take advantage of the Annual Health Assessment (AHA) or other yearlypreventative exam as an opportunity to capture all conditions impacting membercare.

*For more details, see:

Questions? Contact BCBSMT Network Management PDF Document.

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The material presented here is for informational/educational purposesonly, is not intended to be medical advice or a definitive source for codingclaims and is not a substitute for the independent medical judgment of aphysician or other health care provider. Health care providers are encouragedto exercise their own independent medical judgment based upon their evaluationof their patients' conditions and all available information, and to submitclaims using the most appropriate code(s) based upon the medical recorddocumentation and coding guidelines and reference materials. References toother third-party sources or organizations are not a representation, warrantyor endorsement of such organization. Any questions regarding thoseorganizations should be addressed to them directly.