Transcript A-Fib - MultiCultural IPA

InSite User Group Call
February 14, 2012
OI053
Chronic Conditions of the Heart
Focus on: Cardiac Dysrhythmias
Cardiomyopathy
Mary Jo Groome, CCS-P, CPC-H
Sr. Coder Trainer
O1049
Chronic Conditions of the Heart
♥ Heart disease is a general term that involves a wide range of
diseases affecting the heart and blood vessels, including the
following:
Coronary artery disease (CAD)
Category 414
Arrhythmias
Category 427
Congenital heart defects
Categories 745 - 746
Cardiomyopathy
Category 425
Heart infections
Categories 420 - 424
Valvular heart disease
Category 424
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Cardiac Dysrhythmias
 Etiology may be:
– Idiopathic
• Heart disease
– Arteriosclerosis
– Rheumatic heart disease
– Noncardiac
•
•
•
•
Thyrotoxicosis
Alcoholism
Trauma
IV drug use
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Cardiac Dysrhythmias
 Common symptoms of arrhythmias include:
–
–
–
–
–
tachycardia (fast heartbeat)
bradycardia (slow heartbeat)
palpitations or skipped beats
weakness or fatigue
syncope or near syncope
 A heart arrhythmia may not cause any
symptoms and may be identified only
during a regular routine exam.
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Cardiac Dysrhythmias (cont)
 Many cardiac dysrhythmias are chronic
 Acute cardiac dysrhythmias can occur in
– Acute infection
– Digitalis toxicity
 The selection of dysrhythmia codes is dependent on
documentation that could include disturbances in cardiac
rate and rhythm, including abnormalities in the rate,
regularity, and sequence of atrial and/or ventricular
contractions.
 When there is no clear diagnosis, document and code SX/sx
which may include fatigue, light-headedness, decreased
exercise tolerance, or syncope, but often there are no
symptoms.
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427 Cardiac
Dysrhythmias
Coding Overview
Specified Heart Dysrhythmia Codes

Can these cardiac dysrhythmias be documented and coded
to a higher level of specificity?
– Specified Heart Arrhythmias (HCC 92; Factor 0.293)
• 426.0 Atrioventricular block, complete - Third degree atrioventricular block
• 427.0 Paroxysmal supraventricular tachycardia – Rapid atrial rhythm
• 427.1 Paroxysmal ventricular tachycardia - Rapid ventricular rhythm
• 427.2 Paroxysmal tachycardia, unspecified
• 427.31 Atrial fibrillation - Irregular, rapid atrial contractions
• 427.32 Atrial flutter - Regular, rapid atrial contractions
• 427.81 Sinoatrial node dysfunction (severe sinus bradycardia, sinus
bradycardia with tachycardia, or sinus bradycardia with atrioventricular block)
– Arrhythmic-Cardiac Failure (HCC 79; Factor 0.578)
• 427.42 Ventricular flutter - Regular, rapid ventricular contractions
• 427.41 Ventricular fibrillation - Irregular, rapid ventricular contractions
• 427.5 Cardiac arrest –Cardiorespiratory arrest
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Be Specific with Dysrhythmias – Identify the
Problem
Specified Heart Dysrhythmias
HCC 92
Factor 0.293
427.0 Paroxysmal supraventricular tachycardia
- Rapid atrial rhythm
427.1 Paroxysmal ventricular tachycardia
- Rapid ventricular rhythm
427.2 Paroxysmal tachycardia, unspecified
- Idiopathic rapid heart action w/ sudden
onset and cessation (Essential)
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Be Specific with Dysrhythmias – Identify the
Problem
Specified Heart Dysrhythmias
HCC 92
Factor 0.293
427.31 Atrial fibrillation
- Irregular, rapid atrial contractions
427.32 Atrial flutter
- Regular, rapid atrial contractions
427.81 Sinoatrial node dysfunction
- Appears as severe sinus bradycardia,
- sinus bradycardia with tachycardia or
- sinus bradycardia with atrioventricular block
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Be Specific with Dysrhythmias – Identify the
Problem
Specified Heart Dysrhythmias
HCC 79
Factor 0.578
427.42 Ventricular flutter
- Regular, rapid ventricular contractions
427.41 Ventricular fibrillation
- Irregular, rapid ventricular contractions
427.5
Cardiac arrest
- Cardiorespiratory arrest
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Heart Dysrhythmias – Non-specific
Problem Codes
427.89 Cardiac Dysrhythmia,
Other Specified
(i.e. rhythm disorder)
427.9 Cardiac
Dysrhythmia NOS
(i.e. cardiac arrhythmia)
Caution: These are type & location non-specific heart
dysrhythmia codes.
• Coding dysrhythmias to a higher level by specific
type & location of dysrhythmia places these
members into the correct HCC category for
expected medical resource utilization.
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Atrial Fibrillation
(A-Fib)
Overview
A-Fib Coding
 Cardiovascular Disease:
Atrial Fibrillation vs. Atrial Flutter
– Atrial Fibrillation (427.31) is the most common form of cardiac dysrhythmia,
characterized by rapid, randomized contractions of the atrial myocardium
causing a totally irregular, often rapid ventricular rate (400-600 per min) and
may occur in patients with and without other heart disease. Medications may
include Verapamil, Diltiazem, Digoxin, Metoprolol, and Lanoxin to name a few;
and cardioversion may be necessary in some instances.
– Atrial Flutter (427.32) is a condition of cardiac dysrhythmia in which the atrial
contractions are rapid (200-300 per min), yet regular. The ventricles are
unable to respond to each atrial impulse, so that a partial block is usually
present. Atrial flutter frequently occurs in patients with COPD, CAD, and CHF.
Treatment may include Amiodarone, Sotalol, Bretylium, and cardioversion
may be utilized, radiofrequency ablation may also be used for patients with
chronic atrial fibrillation.
• Atrial flutter rarely occurs as an isolated rhythm; it is usually associated
with atrial fibrillation.
American Society of Aerospace Medicine Specialists, . (2011, January 12). Clinical practice guideline for atrial fibrillation and atrial flutter.
Retrieved from
http://webcache.googleusercontent.com/search?hl=en&q=cache:iJrL4UpyAb8J:http://www.asams.org/guidelines/Completed/NEW%20Atrial%2
0Fibrillation.htm+ICD-9+Coding,+A-fib,+as+a+chronic+condition,+after+ablation&ct=clnk
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A-Fib Coding
 Atrial fibrillation (A-Fib) associated with underlying disease should
be coded along with the underlying disease (e.g., hypertension,
hyperthyroidism, congestive heart failure, valvular heart disease,
cardiomyopathy), with the A-Fib considered a complication or
endpoint 427.31 (I48.0).
– This guideline addresses Lone A-Fib, a misleading term in the
cardiac literature which would be better termed idiopathic A-Fib.
• Lone (or idiopathic) A-Fib is defined as A-Fib without structural heart
disease, hyperthyroidism or hypertension in patients under age 60 at
presentation.
• Lone A-Fib may occur as a single isolated episode, recurrent
paroxysmal events or chronically persistent A-Fib.
– Single idiopathic episode often has an identifiable precipitating
cause, such as acute abuse of alcohol and /or stimulants (holiday
heart syndrome).
» Two sets of codes required (substance abuse & A-Fib)
American Society of Aerospace Medicine Specialists, . (2011, January 12). Clinical practice guideline for atrial fibrillation and atrial flutter. Retrieved
from
http://webcache.googleusercontent.com/search?hl=en&q=cache:iJrL4UpyAb8J:http://www.asams.org/guidelines/Completed/NEW%20Atrial%20Fibrill
ation.htm+ICD-9+Coding,+A-fib,+as+a+chronic+condition,+after+ablation&ct=clnk
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A-Fib Coding: Documentation & Coding Tips
 List first the diagnosis code for the
condition, problem, or other reason
for the encounter/visit to be chiefly
responsible for the services
provided.
– Also list additional codes that describe
any coexisting conditions.
 Accurate reporting of ICD-9-CM
codes is important, and the
documentation should describe the
patient’s condition, using
terminology which includes:
– Specific diagnoses as well as symptoms,
problems, or reasons for the encounter.
OptumInsight, 2012. Coders' Desk Reference for Diagnoses: Official ICD-9-CM Coding Guidelines for Coding and
Reporting. USA: Ingenix, 2011. 61-2. Print.
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A-Fib Coding: Documentation & Coding Tips
 Even though the patient presents for
care with condition(s) not chiefly
regarding the A-fib, it is appropriate to
assign a code for chronic A-fib (427.31)
as an additional code, providing the
condition has been evaluated and is
listed in the final diagnostic statement.
– The coding rationale is that the patient requires
ongoing medication for control of this condition.
• Do not assign codes solely from lab reports,
medication sheets, (EKG,) etc.
• If treatment of A-fib includes chronic use of
anticoagulants (except aspirin), code also
V58.61 Long-term “current” use of anticoagulants.
AHA, Coding Clinic. 3rd Q. USA: American Hospital Association, 1995. Print.
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A-Fib Coding: Ablations
 Medications and/or radiofrequency ablation are used for
long term management of paroxysmal and chronic A-Fib
and atrial flutter.
– Paroxysmal and chronic A-Fib often require chronic treatment with
an atrioventricular (AV) node blocking medication, such as a beta
blocker, calcium channel blocker or digitalis for ventricular rate
control.
– Atrial flutter can also be treated with AV node blocking medication,
but control is often difficult to achieve.
– Both A-Fib and atrial flutter may also be treated by radiofrequency
ablation.
• Ablation of atrial flutter is very low risk, technically simple and
essentially 100% curative.
• Radiofrequency ablation for A-Fib is 70 to 85% effective in individuals
with paroxysmal A-Fib and 50 to 70% in individuals with chronic A-Fib.
American Society of Aerospace Medicine Specialists, . (2011, January 12). Clinical practice guideline for atrial fibrillation and atrial flutter. Retrieved from
http://webcache.googleusercontent.com/search?hl=en&q=cache:iJrL4UpyAb8J:http://www.asams.org/guidelines/Completed/NEW%20Atrial%20Fibrillat
ion.htm+ICD-9+Coding,+A-fib,+as+a+chronic+condition,+after+ablation&ct=clnk
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A-Fib Coding: Ablations
 Coding Considerations – If the
patient’s ablation
(electrophysiological procedure)
has resolved the A-fib condition:
– Members that have undergone the
ablation procedure can be
considered “cured” only if clinical
documentation supports a
“resolved” condition:
• Assign V12.50 (History of disease,
cardiovascular system)
• Do not assign the A-Fib code (427.31)
American Society of Aerospace Medicine Specialists, . (2011, January 12). Clinical practice guideline for atrial fibrillation and atrial flutter. Retrieved from
http://webcache.googleusercontent.com/search?hl=en&q=cache:iJrL4UpyAb8J:http://www.asams.org/guidelines/Completed/NEW%20Atrial%20Fibrillat
ion.htm+ICD-9+Coding,+A-fib,+as+a+chronic+condition,+after+ablation&ct=clnk
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A-Fib Coding: Adverse Effects
 Unilateral iliopsoas muscle hematoma due to
anticoagulant use for chronic A-fib.
729.92
427.31
V58.61
E934.2
Nontraumatic hematoma of soft tissue
Chronic atrial fibrillation
Long-term (current) use of anticoagulants
Drugs, medicinals causing adverse effects
in therapeutic use
(anticoagulants)
 Spontaneous ecchymoses due to
anticoagulant use for chronic A-fib.
782.7
427.31
V58.61
E934.2
Spontaneous ecchymoses (petechiae)
Chronic atrial fibrillation
Long-term (current) use of anticoagulants
Drugs, medicinals causing adverse effects
AHA, Coding Clinic. 4th Q. USA: in
American
Hospital Association,
therapeutic
use 2008. Print
(anticoagulants)
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A-Fib Coding: Postoperative A-fib
 Postop A-fib
997.1 Cardiac complications
427.31 Atrial fibrillation
Note: The instructions at the category heading of 997 in
the Tabular of ICD-9-CM tell us to “Use additional code to
identify complications.”
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425 Cardiomyopathy
Coding Overview
425 - Cardiomyopathy
 Cardiomyopathy is a disease
–
–
–
–
involving changes in the heart muscle
that may interfere with the heart’s ability to pump effectively
that may lead to a chronic condition called heart failure
that is sometimes associated with other chronic conditions
• High blood pressure
• Heart valve disease
 Cardiomyopathy presents a clinical picture of:
– Dilated heart
– Flabby heart muscle
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425 - Cardiomyopathy
 The term “cardiomyopathy” may be used for a disease or
disorder classified elsewhere. Indexing is essential.
– Examples:
• “Ischemic cardiomyopathy” indexes to 414.8 (Other specified
forms of chronic ischemic heart disease)
– not a true cardiomyopathy; causes diffuse fibrosis or multiple
infarction, leading to heart failure with left ventricular dilation
• “Stress induced cardiomyopathy” indexes to 429.83 (Takotsubo
syndrome), found under 429.8 (Other ill-defined heart disease)
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425 – Cardiomyopathy (cont)
Includes Myocardiopathy
425.0 Endomyocardial fibrosis
425.1x Hypertrophic cardiomyopathy (HCM)
*425.11 Hypertrophic obstructive cardiomyopathy
(Usually an inherited condition in which the heart muscle becomes thick without any obvious
cause. Younger people usually present with a severe form of HCM that is frequently
asymptomatic and a leading cause of sudden cardiac death in young athletes.) 1
*425.18 Other hypertrophic (not described as obstructive)
425.2 Obscure cardiomyopathy of Africa
425.3 Endocardial fibroelastosis
(Congenital condition characterized by thickening of the endocardium with malformation of
cardiac valves, hypertrophy of the heart and proliferation of elastic tissue in the myocardium.
Many patients due not survive infancy.) 2
* New code in 2012 – no RA designation
Ref: 1 F.Brown’sICD-9-CM Coding Handbook 2012 p 341
Ref 2: 2012 Coders’ Desk Reference p 412
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425 – Cardiomyopathy (cont)
425.4 Other primary cardiomyopathies (J42.8 Other
cardiomyopathies)
NOS
idiopathic
congestive
constrictive
familial
obstructive
restrictive
cardiovascular collagenosis
Note: Cardiomyopathy can result in diastolic dysfunction. If
documentation identifies the diastolic dysfunction is due to
cardiomyopathy, use code 425.4
425.5 Alcoholic cardiomyopathy
Heart disease as result of excess alcohol consumption
Note: If documentation indicates the patient is alcohol dependent
(303.0x or .9x), this should also be coded
2012 Coders’ Desk Reference p 413
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425 – Cardiomyopathy (cont)
425.7 Nutritional and metabolic cardiomyopathy
Code first underlying disease, as:
amyloidosis (277.30-277.39)
beriberi (265.0)
cardiac glycogenoisis (271.0)
mucopolysaccharidosis (277.5)
thyrotoxicosis (242.0-242.9)
425.8 Cardiomyopathy in other diseases classified elsewhere J43
Code first underlying diseases, as:
Friedreich’s ataxia (334.0)
myotonia atrophica (359.21)
progressive muscular dystrophy (359.1)
sarcoidosis (135)
425.9 Secondary cardiomyopathy, unspecified
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425 – Cardiomyopathy Examples
 A patient is seen in the clinic for evaluation of treatment
for hypertensive cardiomyopathy. Record
documentation identifies that the cardiomyopathy was
secondary to hypertensive heart disease.
– 402.90 Unspecified hypertensive heart disease without heart
failure
– 425.8 Cardiomyopathy in other diseases classified elsewhere
 A patient is seen having congestive heart failure and
congestive cardiomyopathy.
– 428.0 Congestive heart failure
– 425.4 Other primary cardiomyopathies
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