AFib with RVR
Good Morning
I need some help please. I looked at old questions here but are unable to find what I am looking for.
What would AFib with RVR code to in ICD-10?
Pt presents to ER with weakness. Afib with RVR and Bronchopneumonia and pleural effusion is diagnosed and POA. AFib with RVR is difficult to control and treatments includes multiple po meds and IV med pushes and IVF for rate and rhythm control. MD documents AFib with RVR is most likely due to the pneumonitis. On day 11 MD documents rate still not controlled. Medication now is po and includes . Bronchopneumonitis with SOB, productive cough, hypoxia and treated with IV abx and nebs . Both conditions eventually resolve but then pt develops hosp acquired pna, resp fx and sepsis and LOS is 30 days.
Coder codes I482 - Chronic A-Fib as the PDX.
I did not think a condition that is documented as uncontrolled and treated with IV meds should be classified as a chronic condition. Coder states "there isn’t a separate code to show that it is uncontrolled or exacerbated and therefor the chronic condition unfortunately has to be the PDX". I thought a more appropriate code would be I481 or even I8491.
Does the physician have to document it as 'persistent' for it to code to I481?
My second question is, would it be inappropriate to code the bronchopneumonia as the PDX in this case rather than a chronic condition?
Thanks in advance for the input!
Renee, RN, CCDS
I need some help please. I looked at old questions here but are unable to find what I am looking for.
What would AFib with RVR code to in ICD-10?
Pt presents to ER with weakness. Afib with RVR and Bronchopneumonia and pleural effusion is diagnosed and POA. AFib with RVR is difficult to control and treatments includes multiple po meds and IV med pushes and IVF for rate and rhythm control. MD documents AFib with RVR is most likely due to the pneumonitis. On day 11 MD documents rate still not controlled. Medication now is po and includes . Bronchopneumonitis with SOB, productive cough, hypoxia and treated with IV abx and nebs . Both conditions eventually resolve but then pt develops hosp acquired pna, resp fx and sepsis and LOS is 30 days.
Coder codes I482 - Chronic A-Fib as the PDX.
I did not think a condition that is documented as uncontrolled and treated with IV meds should be classified as a chronic condition. Coder states "there isn’t a separate code to show that it is uncontrolled or exacerbated and therefor the chronic condition unfortunately has to be the PDX". I thought a more appropriate code would be I481 or even I8491.
Does the physician have to document it as 'persistent' for it to code to I481?
My second question is, would it be inappropriate to code the bronchopneumonia as the PDX in this case rather than a chronic condition?
Thanks in advance for the input!
Renee, RN, CCDS