Documentation & Coding

ATRIAL FIBRILLATION
Atrial Fibrillation (AF) is a common rhythm disturbance, which increases in prevalence with
advanced age. Frequent hospitalization, hemodynamic compromise, and thromboembolic
events related to AF result in significant morbidity and mortality. AF is associated with a 5-fold
increased risk of stroke (which increases with age), a 3-fold increased risk of heart failure (HF),
and a 2-fold increased risk of both dementia and death.*
Atrial Fibrillation classifies to the following specified ICD-10 codes:
• Paroxysmal • Persistent • Permanent

ICD-10-CM DESCRIPTION
I48.0 Paroxysmal Atrial Fibrillation-intermittent, stopping by itself within 7 days
Long-Lasting Persistent Atrial Fibrillation-lasts longer than a year and subject to rhythm control
I48.11
strategy
Other persistent atrial fibrillation NOS chronic persistent atrial fibrillation and persistent atrial
I48.19
fibrillation. Continuous atrial fibrillation that lasts more than seven days
I48.20 Chronic, unspecified (use of one of the more specific descriptive terms is preferred)
Permanent atrial fibrillation Atrial fibrillation that occurs when an irregular heart rhythm is unable to
I48.21
be corrected with treatment and continues indefinitely
I48.91 Unspecified Atrial Fibrillation-physician does not know or state type (common with new onset aFib)

To validate the reporting of this condition / diagnosis accurately document the following:
• All applicable descriptors (paroxysmal, persistent, permanent, etc.)
• Signs and symptoms (irregular rhythm, tachycardia, lightheadedness, chest pain,
palpitations, shortness of breath, fatigue, etc.) and link them to the aFib as appropriate.
• Status (controlled by medication, stable, worsening, improving, etc.)
• Historical with risk of recurrence versus current
• Note: Do not use the descriptor “history of” to describe current atrial fibrillation. Report
“history of aFib” only if the patient’s aFib is resolved and not being treated.
• Clearly link atrial fibrillation to any medications specifically used for active treatment.
Specific and concise treatment plan with clear linkage for each medication. (eg: anti-
arrhythmic to control heart rate and rhythm, long-term use of anticoagulant to prevent
blood clots)
Clinical Pearl: The diagnosis of AF is based on the patient’s clinical history and physical exam.
All patients should have the diagnosis confirmed with an electrocardiogram (ECG). Obesity,
smoking, exercise and increased age may contribute to an increased risk of AF. Some of these
risks are preventable through lifestyle changes such as weight loss, smoking cessation and
control of blood pressure.**
*Reference: January CT, et al. J Am Coll Cardiol. 2014; 64: e1-76.
** Reference: January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial
Fibrillation, J Am Coll Cardiol. 2014;64(21): e1-76
This document is provided by Lumeris solely for education purposes. The information herein is not intended to supersede a
provider’s judgment, standard of care or be deemed exhaustive of all proper methods of care. While a summary of
recommendations from recognized clinical guidelines is presented, no formal practice recommendations by Lumeris should be
inferred. The applicability of the information, including any recommendation, must be assessed by the treating physician in light of
all relevant circumstances presented by an individual patient. This document is subject to periodic revision.
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