![]() ![]() I appreciate that HCC coders do not want to look like they are cooking the books and inflating the risk adjustment score. You could capture personal history codes, but the patient no longer has a current cardiac condition. What if a patient undergoes a successful maze procedure for AF, reverts to normal sinus rhythm, and stays in sinus? That would be curative. They may even remain on anticoagulation or medication for rate control. If the pacemaker were to malfunction or to be turned off, the observed rhythm would be AF in such a patient. In his case, his post-discharge pacemaker check showed it was only operating 4 percent of the time. The bradycardia and pacemaker firing could also be only intermittent, like in my father’s situation. The AF is still present, underlying the paced rhythm. It is not resolving or eradicating the atrial fibrillation. If a patient has AF with a slow ventricular response, a pacemaker is addressing the pauses or bradycardia, the resultant symptoms or the risk of a nine-second asystole – like my father had. They are not in a persistent state of cardiac arrest it is historical. If a patient has an episode of sudden cardiac arrest from which they are resuscitated, and has an AICD implanted, they would carry a diagnosis of Z86.74, Personal history of sudden cardiac arrest and Z95.810, Presence of automatic cardiac defibrillator. They may still have osteoarthritis elsewhere, but the arthritic hip has been eliminated. If a patient has an arthritic right hip and undergoes a hip replacement, after the surgery, they no longer have that arthritic hip, M16.11 they have a replaced hip joint, Z96.641. The Coding Clinic includes “other significant heart rhythm abnormality” in its recommendations. This advice was updated on page 33 of the edition issued for the first quarter of 2019, with the guidance that SSS is considered to still be present and is a legitimate, reportable chronic condition. Historically, the advice of Coding Clinic, stemming back to 1993, was that once a pacemaker was placed for SSS, you only coded the pacemaker’s presence. AF with a slow ventricular response is sometimes included in this grouping, although my father’s electrophysiologist says this isn’t really accurate, because the sinus node is not functioning in atrial fibrillation. I think the confusion and conflicting practice stems from past Coding Clinic rulings regarding sick sinus syndrome (SSS), an umbrella term for abnormal heart rhythms caused by malfunction of the sinus node, or the heart’s natural pacemaker. We need to code conditions that are present and relevant. Research and epidemiological analysis depend on comprehensive capture of conditions (shameless plug for the social determinants of health, or SDoH, here). Population health prospective risk adjustment allots resources according to predicted resource utilization. Complete and accurate coding helps us judge the quality of care provided. We translate the acute patient encounter into codes to determine reimbursement. The pacemaker does not directly treat atrial fibrillation, and it certainly does not cure or resolve it. It is less common to insert a pacemaker for overdrive atrial pacing. Pacemakers in atrial fibrillation are most commonly placed for symptomatic bradycardia, either medication-induced or due to aging, diseased heart muscle. Anticoagulation is often prescribed, because clots can form in the heart and be embolized to the brain, causing strokes. AF often results in a rapid heartbeat, and the treatment is either cardioversion to a normal sinus rhythm, or rate control. Changes in the anatomy and electrophysiology of the smaller upper chambers of the heart, or atria, cause chaotic electrical impulses, which are unpredictably propagated to the lower chambers, or ventricles, causing irregular contraction of the heart muscle. Due to a prior pacemaker infection with sepsis, the cardiologist opted to implant a most remarkable leadless micra pacemaker, even though his patient had already popped back into his usual atrial fibrillation at a rate of 105.Ītrial fibrillation (AF) is the most common cardiac dysrhythmia, afflicting between 2 and 6 million people in the United States. I have a greater appreciation for this after my father had a recent admission for a heart rate of 27. Some say once the pacemaker is placed, they should only code the pacemaker.” She then asked my opinion. Some say because the PCP has to prescribe medications, they should still be able to code afib. Our listeners and readers ask the most interesting questions! One named Dena recently wrote me and said, “I am an HCC coder, and there is a hot debate about coding atrial fibrillation after pacemaker implant. Dysrhythmias like complete heart block, AF, and SSS all fall into HCC 96, with a risk adjustment factor of 0.268. ![]()
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