The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. In addition, some sites may require you to agree to their terms of use and privacy policy. The site may also contain non-Medicare related information. This new site may be offered by a vendor or an independent third party. Questions? Contact your BCBSNM Network Representative.īy clicking this link, you will go to a new website/app ("site"). BCBSNM Medicare Advantage Annual Wellness Visit Guide.Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance.2021 ICD-10-CM (Chapter 9: Diseases of the Circulatory System).ICD-10: I48.91 (If supported by documentation, a more specific code than 148.91 should be used.) Plan: Continue digoxin for AF and follow up in three months. Progress Note: Assessment: Atrial fibrillation, stable and controlled with digoxin. Take advantage of the Annual Health Assessment (AHA) or other yearly preventative exam as an opportunity to capture all conditions impacting member care.Note complications with an appropriate treatment plan.Document each diagnosis as having been monitored, evaluated, assessed and/or treated on the date of service.Ensure documents are signed and dated by a credentialed provider.Document legibly, clearly and concisely.Include patient demographics, such as name and date of birth, and date of service in all progress notes.The type of AF (paroxysmal, persistent, permanent or history of) should be documented consistently throughout the note to avoid unspecified codes that don’t fully define the member’s condition. Only one code may be assigned for a specific type of AF.Document in the note any current associated physical exam findings (such as irregular heart rhythm or increased heart rate) and related diagnostic testing results.In coding, "history of" indicates a condition is no longer active.Code I48.19, Other persistent atrial fibrillation, should be assigned. Chronic persistent AF has no widely accepted clinical definition or meaning.Chronic AF, unspecified (I48.20) may refer to any persistent, longstanding persistent or permanent AF.Permanent AF (I48.21) is persistent or longstanding persistent AF where cardioversion cannot or will not be performed, or is not indicated.Persistent AF (I48.11) describes AF that does not terminate within seven days, or that requires repeat pharmacological or electrical cardioversion.This guidance is from the ICD-10-CM Official Guidelines for Coding and Reporting and industry-approved sources.Īccording to ICD-10-CM guidelines,these four unique codes describe the types of AF: Below are tips for documenting and coding atrial fibrillation (AF). High quality documentation and complete, accurate coding can help capture our members’ health status and promote continuity of care.
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