Primary Care Coding Alert

You Be the Coder:

Can You Code This Abnormal Atrial Rhythm Scenario?

Published on Tue Jan 16, 2024

Question: Our primary care practitioner (PCP) recently saw a patient for a follow-up visit who has a history of both atrial fibrillation and atrial flutter. The physician’s note states: “Patient is stable, no new complaints. Continues on medication for atrial rhythm abnormality. EKG shows atrial activity consistent with previous diagnoses.” How do I code this?

Ohio Subscriber

Answer: This one likely will require a query. The physician’s note is vague about the current condition. It mentions “atrial rhythm abnormality” but does not specify whether the patient is currently experiencing atrial fibrillation or atrial flutter. Choosing the incorrect code could potentially impact the patient’s medical record and future treatment plans. It could also affect billing if coverage of some services differs between the two conditions.

Atrial fibrillation (A-fib) and atrial flutter are two different conditions that are both examples of tachycardia caused by arrhythmias. Tachycardia occurs when a patient’s heart beats too quickly. Usually, tachycardia is described as a heart rate of over 100 beats a minute at rest.

Tachycardia sometimes has other symptoms as well, such as dizziness, shortness of breath, and chest pain. Common testing for tachycardia includes electrocardiograms (EKGs) and stress tests. But again, the notes in this instance are vague and do not clearly point to one condition or the other.

Ideally, the documentation would contain details that tell you exactly which A-fib and atrial flutter code to report.

Bottom line: Without more information, you should query your provider for clarification. For your reference, and to possibly help with your query, consider the following:

A-fib: With A-fib, the atria quiver or fibrillate rather than beating normally. Your ICD-10-CM options for A-fib are as follows:

I48.0 (Paroxysmal atrial fibrillation)
I48.11 (Longstanding persistent atrial fibrillation)
I48.19 (Other persistent atrial fibrillation). This code includes chronic persistent atrial fibrillation and persistent atrial fibrillation, NOS.
I48.20 (Chronic atrial fibrillation, unspecified)
I48.21 (Permanent atrial fibrillation)
I48.91 (Unspecified atrial fibrillation)

Atrial flutter: With atrial flutter, rapidly fired signals make the muscles in the atria contract quickly, which leads to a fast, steady heartbeat. Your ICD-10-CM options for atrial flutter are as follows: