Atrial Fibrillation

Good morning,
We are working on becoming more consistent with query for specificity of A Fib (persistent, paroxysmal, chronic etc).  Most of my attendings feel that "with RVR" is as specific as it gets, so lots of room to educate.  The question that has come up most recently is the New Onset A Fib.  I understand that payors are cracking down on unspecified codes for pdx), and yet new onset a fib is sometimes the pdx:  using persistent, paroxysmal, chronic,etc often are not appropriate choices.  How are you all handling this one?

Comments

  • edited May 2017

    Please clarify the new onset Atrial Fibrillation 

    Classification

    Clinical AF is defined as an episode that lasts longer than 30 seconds. Lone AF refers to AF in patients younger than 60 years without coexisting heart disease. Following initial presentation, 

    AF can be categorized as:

    Paroxysmal AFepisodes of AF terminating spontaneously within 7 days or cardioverted within 48 hours of onset

    Persistent AF—episodes of AF lasting greater than 7 days or cardioverted after 48 hours of onset

    Longstanding persistent AF— continuous AF of greater than 12 months’ duration

    Permanent AF—restoration and maintenance of sinus rhythm has either failed or a decision has been made to not attempt rhythm control (refers to patients for whom a decision has been made not to restore or maintain sinus rhythm by any means, including catheter or surgical ablation)


    Ref :Zipes Cardiac Electrophysiology: From Cell to Bedside

    Chapter 75

    Copyright © 2014,

  • so the only one really that would be applicable to a new onset would be Paroxysmal since the pt often wouldn't be in the hospital long enough to know if it's persistent and permanent wouldn't be applicable in this case?
  • I agree with the above. When the patient presents to the ER with symptoms that have been going on for a couple of days or more and they decide to cardiovert electronically or chemically, some of our MDs will call it persistent believing that the AF has been going on at home for at least 48 hours prior to presenting in the ED. 
  • that makes sense to me, thanks Ellen for responding
  • so the only one really that would be applicable to a new onset would be Paroxysmal since the pt often wouldn't be in the hospital long enough to know if it's persistent and permanent wouldn't be applicable in this case?

    But all readmissions for up to a year or as long as the MD is actively trying to convert a fib, is modifying the medication regimen, has scheduled cardiologist consults for it, has EPS studies or planned procedures such as ablation etc. then it would continue to be classified as "persistent".  It becomes chronic when the patient and family agree to focus on chronic rate control and anticoagulation and "live with it".     The time frame and treatment matters.
  • Thanks Allan, would you please weigh in on the scenario that the patient is admitted and truly it is a new onset of A fib. What would you expect to see as far as the specificity of A fib?
  • Classification

    Clinical AF is defined as an episode that lasts longer than 30 seconds. Lone AF refers to AF in patients younger than 60 years without coexisting heart disease. Following initial presentation, 

    AF can be categorized as:

    Paroxysmal AFepisodes of AF terminating spontaneously within 7 days or cardioverted within 48 hours of onset

    Persistent AF—episodes of AF lasting greater than 7 days or cardioverted after 48 hours of onset

    Longstanding persistent AF— continuous AF of greater than 12 months’ duration

    Permanent AF—restoration and maintenance of sinus rhythm has either failed or a decision has been made to not attempt rhythm control (refers to patients for whom a decision has been made not to restore or maintain sinus rhythm by any means, including catheter or surgical ablation)


    Ref :Zipes Cardiac Electrophysiology: From Cell to Bedside

    Chapter 75

    Copyright © 2014,

    Classification

    Clinical AF is defined as an episode that lasts longer than 30 seconds. Lone AF refers to AF in patients younger than 60 years without coexisting heart disease. Following initial presentation, 

    AF can be categorized as:

    Paroxysmal AFepisodes of AF terminating spontaneously within 7 days or cardioverted within 48 hours of onset

    Persistent AF—episodes of AF lasting greater than 7 days or cardioverted after 48 hours of onset

    Longstanding persistent AF— continuous AF of greater than 12 months’ duration

    Permanent AF—restoration and maintenance of sinus rhythm has either failed or a decision has been made to not attempt rhythm control (refers to patients for whom a decision has been made not to restore or maintain sinus rhythm by any means, including catheter or surgical ablation)


    Ref :Zipes Cardiac Electrophysiology: From Cell to Bedside

    Chapter 75

    Copyright © 2014,


  • I recommend this paper as it goes over the new onset scenario and definitions.
    2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design
  • Thanks Allan, would you please weigh in on the scenario that the patient is admitted and truly it is a new onset of A fib. What would you expect to see as far as the specificity of A fib?


    I actually would like it if we got some direction from the cooperating parties since they insist on giving us ICD 10 codes which our physicians often don't have definitions for.   Write to them!

    Having said that, I largely agree with the criteria above and this is an are where we recommend taking the criteria to your cardiologists at your hospital and working out what criteria will be official designated for your facility, until such time that the guidance is updated with some definitions that is.

    I don't often see the long standing permanent strategy used, but I think it would be completely appropriate for situations where active treatment is still under way, even if that active treatment comes in the form of visits to the doctors office and continued testing and treatment (which may not be actively going on during an admission but would still put it into that category).

  • thanks for your insight, much appreciated!
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