# Atrial fibrillation with pacemaker



## pwoodwo48 (Mar 27, 2012)

Hi all,
My office is having an ongoing debate as to whether it is appropriate to code Atrial fibrillation (427.31) when a patient has a pacemaker (V45.01). The Afib is not a problem at this time.
Any thoughts? thanks in advance...and if you could direct me to any resources that would be great!


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## vj_tiwari (Mar 27, 2012)

Hey 

Is it possible to share the reason for encounter???

I think 427.31 is chronic condition & if patient is on meds for ths same then we need to code 427.31 along with V45.01 (if mentioned) & V58.6* codes.


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## Makana2k5 (Jun 22, 2012)

*Afib + PM*

I think it's supposed to be changed to SSS 427.81 after the pacemaker.


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## tinacolassard (Nov 7, 2013)

Per clinic do not code sss if the patient has a documented pacemaker.  Code only the pacemaker.


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## lucihoo (Feb 3, 2014)

*Afib s/p PPM-to code or not to code?*

I know the conversation I'm replying to is a bit old, but I am still having problems with whether or not to code A-FIB, s/p PPM placement, not SSS. I have it clear on the SSS, no code w/PPM, unless there are sxs. On the A-FIB, not so clear...the documentation I have says "A-fib, patient s/p PPM, on _Coumadin, no asymptomatic_" 
Couldn't locate any coding clinic info on the A-fib, only the SSS. Any thoughts anyone? 
Thanks!


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## lucihoo (Feb 3, 2014)

*Changing AFib to SSS??*

And as an aside, I have never heard of changing a diagnosis of A-Fib, to SSS after a PPM is placed?? That's a total new one on me!


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## AlainaMichelle (Mar 5, 2015)

*Pacemaker for A-fib*

Hello, This is a very old thread however I'd like to post my opinion. I am an HCC coder and I am working on a compliance plan for our work. For A-Fib with a pacemaker palced specifically for that reason we are not supposed to code for Afib any longer, as it is corrected with the pacemaker. This is the only circumstance I have seen for not coding A-fib. For anything else (on meds to control, asymptomatic, history of a-fib) we can code for it becuase it is a chronic condition. We can also code for it if the pacemaker is put in for another reason other than a-fib and it happens to control it. 
Just thought I'd share because this is something I have been looking into lately.


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## balamurugan.ph (Mar 6, 2015)

AlainaMichelle said:


> Hello, This is a very old thread however I'd like to post my opinion. I am an HCC coder and I am working on a compliance plan for our work. For A-Fib with a pacemaker palced specifically for that reason we are not supposed to code for Afib any longer, as it is corrected with the pacemaker. This is the only circumstance I have seen for not coding A-fib. For anything else (on meds to control, asymptomatic, history of a-fib) we can code for it becuase it is a chronic condition. We can also code for it if the pacemaker is put in for another reason other than a-fib and it happens to control it.
> Just thought I'd share because this is something I have been looking into lately.



Even pacemaker put for another reason or a fib, we can code A-fib because it is chronic condition even Pacemaker insert also we can give as status code for Pacemaker. but this visit reason should be follow up of A-fib.


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## chaimz (Mar 10, 2015)

balamurugan.ph said:


> Even pacemaker put for another reason or a fib, we can code A-fib because it is chronic condition even Pacemaker insert also we can give as status code for Pacemaker. but this visit reason should be follow up of A-fib.



I have to agree with AlainaMichelle. I'm an HCC coder as well, and what she said is word for word what I learned.


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## lgardner (Mar 10, 2015)

AlainaMichelle said:


> Hello, This is a very old thread however I'd like to post my opinion. I am an HCC coder and I am working on a compliance plan for our work. For A-Fib with a pacemaker palced specifically for that reason we are not supposed to code for Afib any longer, as it is corrected with the pacemaker. This is the only circumstance I have seen for not coding A-fib. For anything else (on meds to control, asymptomatic, history of a-fib) we can code for it becuase it is a chronic condition. We can also code for it if the pacemaker is put in for another reason other than a-fib and it happens to control it.
> Just thought I'd share because this is something I have been looking into lately.



Can you point me to any official documentation that states this?


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## Hipoink (Mar 18, 2015)

I agree! 427.31,V45.01, and V58.61 is what I would code. I code both ED and HCC. History of afib, corrected by pacer, and monitored by therapeutic anticoag.


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## julie13 (Apr 28, 2015)

*Pacemaker for A-fib*

AlainaMichelle can you please provide a reference or source? I'm a HCC coder as well and everything I've read leads me to the ICD-9 guideline that states you cannot code a condtion as active if that condition no longer exists, which is the case when the pacemaker controls the a-fib.


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## j.monday7814 (Apr 29, 2015)

I think the misinterpretation is coming from the idea that the pacemaker is "correcting" the atrial fibrillation. pacemakers do not "correct" it, they pace over the hearts normal pacing function but the patient still has underlying atrial fibrillation. Any underlying rhythm can be seen during the device evaluation (PM or ICD) since it is still physiologically active.

For all device evaluations we would use any arrhythmia that has occurred since the last interrogation/programming as the primary diagnosis code but if they have not experienced an arrhythmia then we would use the indication for the implant since it is a chronic condition still being managed by the physician through the device. Arrhythmias do not go away with implantation of a device, ablations are the only procedures that actually eliminate arrhythmias.


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## kksmom (May 14, 2015)

One scenario where we do not code Atrial Fib on an ongoing basis is when it occurs as a short term, time limited event that is treated and no longer active.  We see this happen at times during procedures or inpatient stays.  A Fib is coded at the time, for that event, but is not coded on an ongoing basis if there is no continued treatment (medication or pacer) in the long term.  THis is seen frequently in HCC coding when we look for gaps over time.


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## camillecoder@hotmail.com (Mar 1, 2016)

Having been an HCC coder I do not recall seeing any documentation from an official source that indicates that one doesn't code afib if it's s/p pacer.  I would argue that the risk (which is what HCC is all about) hasn't changed much and the cost of caring for that patient with a pacer is still high because that patient has to have regular device checks and generator replacements.  Also, the pacer doesn't cure the afib, it treats it, just as my levothyroxine doesn't cure my hypothyroidism, it only treats it.  Compare that to something like bacterial pneumonia whereby the antibiotic cures the illness.  Once the antibx is finished the pneumonia is gone.  

ICD10 is an improvement for this diagnosis.  There are now three diagnoses, or the 3 P's: Paroxysmal, permanent, persistent.  I haven't seen the updated HCC list since I don't do HCC coding anymore, I wonder whether paroxysmal is a risk-adjusted dx.


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## brett.senor@msj.org (Jun 5, 2016)

*DocDoc*



AlainaMichelle said:


> Hello, This is a very old thread however I'd like to post my opinion. I am an HCC coder and I am working on a compliance plan for our work. For A-Fib with a pacemaker placed specifically for that reason we are not supposed to code for Afib any longer, as it is corrected with the pacemaker. This is the only circumstance I have seen for not coding A-fib. For anything else (on meds to control, asymptomatic, history of a-fib) we can code for it because it is a chronic condition. We can also code for it if the pacemaker is put in for another reason other than a-fib and it happens to control it.
> Just thought I'd share because this is something I have been looking into lately.



I respectfully disagree. A pacemaker is never used to treat atrial fibrillation. Never. It IS used to treat the sequela of treatment of afib: either meds that induce a symptomatic bradycardia in cases where meds are felt to be necessary to continue (but afib is still there lurking beneath) or if treated with AV nodal ablation, in which case the patient will develop a high-grade conduction block (usually 3rd degree heart block). But in all of these it is the malignant bradycardia that dictates the PPM placement. In this last case the ablation may cure the afib but supplants it with the need for a pacer. Otherwise these are patients with atrial fibrillation (either persistent or chronic) with a PPM for the malignant bradycardia.

IF that coding rule is in place it makes no sense whatsoever, except in the last scenario described. Do we code hypertension for patient with normal BPs due to her lisinopril? Do we code diabetes in patient with normal blood sugars because of good compliance to diet, exercise and insulin use? 

Please point out my error in logic if it exists.

$0.02 from a hospitalist physician/CDI physician advisor


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## jmdalton (Jun 21, 2016)

The AAPC CRC course material discusses the pacemaker/conduction disorder. I wish they would make the material (after another proofreading) available for purchase separate from the course.

AAPC would likely frown on me posting the whole excerpt, but here's a snippet:



> Sometimes atrial fibrillation can be a short event or converted and other times it is a life-long diagnosis. In rare cases, a pacemaker may be implanted
> for the treatment of A-Fib, and once a pacemaker is placed and working, then the A-Fib should not be coded unless the pacemaker was implanted for other conduction problems.
> 
> If the patient has more than one conduction disorder, for example a history of sick sinus syndrome (or SA node malfunction) as well as A-Fib, and there is a pacemaker in place, the patient likely still has A-Fib and this can be revealed by the current use of Coumadin or warfarin, other blood thinner, or A-Fib medication. Pacemakers are most often implanted for SA node malfunction or sick sinus syndrome and not for A-Fib.



Risk Adjustment—Predictive Modeling, Documentation, & Capture of Diagnosis Code, from AAPC, p. 50 (CRC class material)


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