References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. 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. 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. In addition, some sites may require you to agree to their terms of use and privacy policy. The site may also contain non-Medicare related information. This new site may be offered by a vendor or an independent third party. Questions? Contact BCBSMT Network Management.īy clicking this link, you will go toa new website/app ("site"). BCBSMT Medicare Advantage Annual Wellness Visit Guide.Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (RADV) Medical RecordChecklist and Guidance.2021 ICD-10-CM (Chapter 9: Diseases of the Circulatory System).Take advantage of the Annual Health Assessment (AHA) or other yearly preventative exam as an opportunity to capture all conditions impacting member care.Note complications with an appropriate treatment plan.Document each diagnosis as having been monitored, evaluated, assessed and/or treated on the date of service.Ensure documents are signed and dated by a credentialed provider.Document legibly, clearly and concisely.Include patient demographics, such as name and date of birth, and date of service in all progress notes.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. Only one code may be assigned for a specific type of AF.Document in the note any current associated physical exam findings (such as irregular heart rhythm or increased heart rate) and related diagnostic testing results.In coding, "history of" indicates a condition is no longer active.Chronic persistent AF has no widely accepted clinical definition or meaning.Chronic AF, unspecified (I48.20) may refer to any persistent, longstanding persistent or permanent AF.Permanent AF (I48.21) is persistent or longstanding persistent AF where cardioversion cannot or will not be performed, or is not indicated.Persistent AF (I48.11) describes AF that does not terminate within seven days, or that requires repeat pharmacological or electrical cardioversion.This information is from the ICD-10-CM Official Guidelines for Coding and Reporting and the sources listed below*.Īccording to ICD-10-CM guidelines,these four unique codes describe the types of AF: Below are resources for documenting and coding atrial fibrillation (AF). High quality documentation and complete,accurate coding can help capture our members' health status and promote continuity of care.
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