Documentation and Coding Guidance - Atrial Fibrillation

Feb. 01, 2021

High quality documentation and complete,accurate coding can help capture our members' health status and promote continuity of care. Below are resources for documenting and coding atrial fibrillation (AF). This information is from the ICD-10-CM Official Guidelines for Coding and Reporting  and the sources listed below*.

Codes for AF Types
According to ICD-10-CM guidelines,these four unique codes describe the types of AF:

• Persistent AF (I48.11) describes AF that does not terminate within seven days, or that requires repeat pharmacological or electrical cardioversion.
• Permanent AF (I48.21) is persistent or longstanding persistent AF where cardioversion cannot or will not be performed, or is not indicated.
• Chronic AF, unspecified (I48.20) may refer to any persistent, longstanding persistent or permanent AF.
• Chronic persistent AF has no widely accepted clinical definition or meaning. Code I48.19,Other persistent

atrial fibrillation, should be assigned.

Active AF vs. "History of" AF

• In coding, "history of" indicates a condition is no longer active.
• Document in the note any current associated physical exam findings (such as irregular heart rhythm or increased heart rate) and related diagnostic testing results.
• Only one code may be assigned for a specific type of AF. 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.

Best Practices

• Include patient demographics, such as name and date of birth, and date of service in all progress notes.
• Document legibly, clearly and concisely.
• Ensure documents are signed and dated by a credentialed provider.
• Document each diagnosis as having been monitored, evaluated, assessed and/or treated on the date of service.
• Note complications with an appropriate treatment plan.
• Take advantage of the Annual Health Assessment (AHA) or other yearly preventative exam as an opportunity to capture all conditions impacting member care.

*For more details, see:

• 2021 ICD-10-CM  (Chapter 9: Diseases of the Circulatory System)
• AHA Coding Clinic, Q2, Q4 2019
• Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (RADV) Medical RecordChecklist and Guidance 
• BCBSMT Medicare Advantage Annual Wellness Visit Guide

Questions? Contact BCBSMT Network Management.

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The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients' conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.