AFib with RVR

rfoster@kdhcd.org

Just had a question. If a patient comes in with a secondary Dx of AFib with RVR are you able to use the RVR as a CC? We have had some discussion at length at our facility about this issue and from the clinical side, the RVR requires more interventions, meds, etc to treat whereas AFib by itself does not require the same interventions. When we put it through the encoder there is an option for Paroxysmal SVT which is what RVR is assumed to be. Any thoughts on this? Thank you for any input you might have.

Rebekah Foster RN CCDS
Interim Manager of CDI
Kaweah Delta Medical Center
400 W. Mineral King
Visalia, CA 93291
(559) 624-5085

jschoonhoven

"Assumed to be" is a red flag considering our line of work :-)

A-fib that is chronic and managed successfully in the home or hospital environment does not code to a CC. The opportunity to show severity in the acute care environment is in looking at the patient's overall condition. Did they come in in Acute on chronic systolic or diastolic HF? You can take the out of control A-fib as PDX and the HF for your MCC IF the afib is being specifically treated (dilt drip, etc). We do that here routinely because it does show the impact of the patients out-of-control chronic condition.

Is there evidence of demand ischemia? Again, the A-fib can be PDX and you can capture the severity by coding the accompanying issues.

Always interesting...
Janice

Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network

lconaway@altoonaregional.org

PSVT 427.0
Afib 427.31

Unfortunately, I think the following section of the official guidelines for coding and reporting prevents us from being able to capture both...

3. Level of Detail in Coding
Diagnosis and procedure codes are to be used at their highest number of digits available.
ICD-9-CM diagnosis codes are composed of codes with 3, 4, or 5 digits. Codes with three digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater detail.
A three-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth-digit subclassifications are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits required for that code. For example, Acute myocardial infarction, code 410, has fourth digits that describe the location of the infarction (e.g., 410.2, Of inferolateral wall), and fifth digits that identify the episode of care. It would be incorrect to report a code in category 410 without a fourth and fifth digit.

Clinically, I completely agree that uncontrolled afib should be reflected in the severity somehow as it can encompass so much more in terms of IV drips, tele or ICU beds, hourly vitals, etc. But if I am interpreting the above correctly, I think we are stuck only coding the most detailed code for the afib. As Janice said, I would either try and capture it as principal or look for other conditions that often accompany fast afib. (acute or chronic CHF, USA etc)





LeeAnn Cheung-Conaway RN III, CCRN, CCDS

UPMC Altoona, Quality Management Dept.

Clinical Documentation Specialist - Coordinator

Office 814-889-3313

Cell 814-502-6772

Fax 814-889-3766

deanne_wilk

I agree. Being also a coder we dont code RVR. Just afib. Maybe have a discussion with docs on this for future documentation as to the PSVT vs Afib with RVR. I was not aware of that so thank you.

evanspx@sutterhealth.org

Paroxysmal SVT, if and when present and documented, should be coded separately from Atrial Fibrillation - these are separate conditions and we are allowed to code these separately.




Paul Evans, RHIA, CCS, CCS-P, CCDS

lconaway@altoonaregional.org

I agree that they can be coded separately if the pt is having 2 separate types of dysrhythmias but if the only dysrhythmia is atrial fibrillation with a fast ventricular rate, you can't capture both codes for the same condition. Atrial fib (when its fast) is a type of PSVT but there are many other types. PSVT simply means the fast heart rate originates above the ventricles. For example, if the pt was having episodes of paroxysmal atrial tachycardia (this rhythm is regular but intermittently fast) and episodes of atrial fibrillation (which is an irregular rhythm), both could be coded. But in the instance as was originally described, only the atrial fib can be coded and you wouldn't see a physician document "PSVT" when the pt has a more specific diagnosis of rapid afib.

LeeAnn Cheung-Conaway RN III, CCRN, CCDS
UPMC Altoona, Quality Management Dept.
Clinical Documentation Specialist - Coordinator
Office 814-889-3313
Cell 814-502-6772
Fax 814-889-3766

rfoster@kdhcd.org

Thank you all for your answers. So what I think I hear you all saying is that in order to code the RVR it would have to state Paraxysmal SVT in addition to the Afib, is that correct? Otherwise Afib with RVR will just code to Afib. Not a coder, so the nuances and rules of the coding part, trip me up sometimes, so I really appreciate any help you all are giving. It is very valuable!

Rebekah Foster, RN CCDS
Interim Manager of CDI
Kaweah Delta Medical Center
400 W. Mineral King
Visalia, CA 93291
(559) 624-5085

deanne_wilk

Correct

cynthia.hudson@christushealth.org

We code ventricular tachycardia with the afib, but the physician has to document the RVR.

Syndi Hudson, RN, CCM

CDI Specialist

Christus Santa Rosa New Braunfels

600 North Union

New Braunfels, Texas 78130

cynthia.hudson@christushealth.org

830-643-6116 (Office)

830-643-5139 (Fax)



"I press on toward the goal to win the prize for which God has called me." Philippians 3:14

cynthia.hudson@christushealth.org

Afib with RVR is atrial fib-one condition and rapid ventricular response. It is causing the ventricles to contract rapidly and if not stopped, this can become ventricular fibrillation. RVR is not in the atrium.

Syndi Hudson, RN, CCM

CDI Specialist

Christus Santa Rosa New Braunfels

600 North Union

New Braunfels, Texas 78130

cynthia.hudson@christushealth.org

830-643-6116 (Office)

830-643-5139 (Fax)



"I press on toward the goal to win the prize for which God has called me." Philippians 3:14

lconaway@altoonaregional.org

Atrial fib is a type of Supraventricular tachycardia. It originates above the AV node. Coding ventricular tachycardia would not be appropriate if the pt only had fast afib. Atrial fib with a fast VR still originates above the ventricle and is not a ventricular rhythm. Ventricular tachycardia originates in the ventricles and is typically a wide complex tachycardia whereas atrial fib with a fast VR is a narrow complex tachycardia. VT can deteriorate into Vfib. Afib with a rapid VR does not.

LeeAnn Cheung-Conaway RN III, CCRN, CCDS
UPMC Altoona, Quality Management Dept.
Clinical Documentation Specialist - Coordinator
Office 814-889-3313
Cell 814-502-6772
Fax 814-889-3766

katysuegood@gmail.com

Renee, How did she get to chronic? Did the MD say that? Persistent A-fib is defined as AF that does not self-terminate within 7days. Did their condition meet that definition? If so, this would be an opportunity to query.

As far as the PDX, I think it really depends on the focus of care. If both conditions were POA, equally treated, and equally responsible for admission, then you could code the PNA as pdx and I would certainly advocate doing so.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

evanspx@sutterhealth.org

Query:

On DATE documentation in the NOTE TYPE section of the medical record indicates the patient has atrial fibrillation. Clinical evaluation / treatment includes ***.

Please clarify the type of atrial fibrillation for this patient.

You may answer this Query by marking the checkbox(es) below or using free text at the ( * ) if appropriate.

Provider Query Response:*

Past history, no longer requiring treatment
Paroxysmal
Persistent
Chronic and/or permanent
Unspecified
Unable to determine
Other (please specify)*

renmeyer@sbcglobal.net

Thanks again! Great query, thank you Paul.

Katy the CDI did not query while the pt was in house. MD documented Atrial fibrillation with RVR. Coder stated that because there is not a specific code to show uncontrolled or exacerbated, she had to code the chronic condition. It also wasn't queried retrospectively. It's always hard to decide if two conditions was treated equally. The AFib was more in the foreground while MD was trying to find a suitable medication to control the rate and rhythm. The pneumonia was quietly taking its course in the background. You know how that goes. Doesn't necessarily means pna was treated less, but definitely a harder sell.

The DRG will remain the same regardless of which code is used for AFib so I'm now just wondering if a code for a chronic condition can be the PDX? When we did our training we were told a chronic condition could not be a PDX unless it became acute or exacerbated and then it will be coded as such. Coder states differently and states a chronic condition can absolutely be the PDX. So now I'm totally confused.

Thanks again for all the help!

Renee, RN CCDS

evanspx@sutterhealth.org

Currently, there is not a code for 'acute on chronic' Atrial fibrillation, and it seems this is complicating the issue. If a patient with established A-Fib that is known and documented to be chronic experiences 'breakthrough' and an exacerbation of the chronic form of AFib, then indeed, that code should be used as the principal diagnosis, as per your statement, Renee.






The most recent definitions for AF, according to AHA/ACC/HRS 2014 AF therapy guidelines are:

1) Paroxysmal AF: terminates (spontaneously or with intervention) within 7 days

2) Persistent AF: sustained episode > 7 days

3) Longstanding AF: sustained episode > 12 months

4) Permanent AF: joint decision by patient and clinician to cease further attempts to restore and/or maintain sinus rhythm

5) Nonvalvular AF: AF in absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair

annnd2009@gmail.com

Why not use unspecified afib i48.91??

katysuegood@gmail.com

Well I would argue that if all the provider did was state A-fib with RVR, we should end up with the unspecified code, not the chronic one. Unless they clearly describing a longstanding condition.

As far as whether a chronic condition can be Pdx, as far as I know, there is no guideline that says it can't be. That being said when we are thinking about reason for admission, we are generally talking about acute conditions and exacerbations. This is not a 'rule' though and there certainly are exceptions. There are some potential implications from a denials perspective when chronic conditions are coded as Pdx. I think its helpful to think about whether the PNA alone would have been treated OP if it were not for the A-fib.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Unknown

For all of you to be aware, at the September 22 - 23 meeting of the Coordination and Maintenance Committee, they were presented a series of codes for atrial fibrillation that included "first episode of atrial fibrillation." There has to be a first episode before anyone can consider if a patient has paroxysmal or persistent or longstanding atrial fibrillation. Atrial fibrillation due to a stimulating event such as an acute MI or myocarditis may never recur once the stimulating force is taken care of and, without a "first episode" you can never classify its occurrence. Let's hope this will be adopted soon. We're stuck till then. (Also in discussion is relationship to mitral valve disease as treatment of a fib is different than without mitral valve disease)

Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)