Atrial Fibrillation Outpatient CDI Scenario – April 2021

Topic: Outpatient CDI: Atrial Fibrillation

Office Visit 2/15/2021: 78-year-old gentleman, lives with wife. Recently hospitalized from 1-2-2021 to 1-7-2021 for Acute MI and Atrial fib with RVR. No voiced complaints. No complaints of heart racing, chest pain. Able to walk around house, up and down flight of steps without stopping.  Seen last week by Ostomy Nurse for questions about care of his colostomy and 4 weeks ago by Cardiology for hospital follow up. Follows with OP pharmacy for his INR monitoring. Admits to slight weight gain from the holidays.

PMH: COPD, GE reflux, Atrial fibrillation, Obesity

Home medications: Coumadin, Serevent inhaler, Atrovent inhaler, Prilosec 20 mg capsule QD

Vitals: BP 115/64, HR 98, Temp 98.4, SpO2 96%, Weight 168 lbs., Height 5ft., BMI 32.8

Assessment/Plan:

  • History of atrial fibrillation
  • Myocardial infarction
    • MI- following with Cardiology
    • History of A fib since 2016. Failed ablation in 2018. EKG from office today pending. Cardiology notes state will see in 6 months, discuss continued plan of blood draws and following with hospital Pharmacists. Refusing any further invasive treatment at present. Completed OP cardiac rehab
  • COPD
    • On inhalers, lungs clear, stable today
  • Obesity
    • Counseled on diet, follow diet plan to help with colostomy per Ostomy Nurse
  • Follow-up
    • Return in 6 months

Question: Are there query opportunities based on the scenario stated above?

Discussion:

  • Provider visit notes discuss Atrial Fibrillation as “history”. Patient continues on Coumadin dosing and recent hospitalization with A Fib noted. Previous ablation mentioned and patient refusing further invasive interventions
  • Myocardial infarction hospitalization 1-2-2021 thru 1-7-2021.  Appears patient now s/p MI.

UASI Recommends:

  • Query current status and specificity of atrial fibrillation
  • Query current status of Myocardial infarction
  • Use Colostomy status Z93.3 as current condition

Documentation without Clarification:

Diagnoses:

  1. Myocardial Infarction I 21.4 (HCC 86)
  2. COPD J44.9 (HCC 111)
  3. Obesity E66.9

Factor:

Demographic base factor: Community Enrollee-Non-dual Benefit, aged (Male 75-79): 0.451

HCC 86 risk factor 0.195

HCC 111 risk factor 0.335

Total: 0.981

Documentation with Clarification:

Diagnoses:

  1. Atrial fibrillation, permanent I48.21 (HCC 96)
  2. COPD J44.9 (HCC 111)
  3. Obesity E66.9
  4. Colostomy status Z93.3 (HCC 188)
  5. Personal history of MI I25.2

Factor

Demographic base factor: Community Enrollee-Non-dual Benefit, aged (Male 75-79): 0.451

HCC 96 risk factor 0.268

HCC 111 risk factor 0.335

HCC 188 risk factor 0.534

Total: 1.588

CDI Educational Tips:

‘History of’ can be a vague term and have different meanings. Educate providers to discuss condition(s) in current state and diagnoses that have resolved or are no longer treated should not be reported.

Atrial fibrillation maps to HCC category 96 and has a SOI-2. Educate providers on the types of Afib:

  • Persistent: fails to resolve within 7 days. Episodes often require pharmacologic or electrical cardioversion
  • Paroxysmal: self-terminating Afib. Terminates spontaneously or with intervention within seven days of onset
  • Permanent: joint decision by patient and provider to stop any further attempts to restore or maintain a sinus rhythm
  • Longstanding persistent: lasted for more than 12 months

Clarify what rhythm is present, when “AF” is documented as they could be used to describe atrial flutter or atrial fibrillation.

Review ECG and telemetry strips closely for any significant arrythmias noting treatment provided. Codes cannot be assigned based solely on ECG or telemetry strips, and if present with treatment, the diagnosis should be reported and may require a query.

When the Myocardial Infarction meets the definition of a reportable diagnosis, codes from category I21 may continue to be reported for the duration of four weeks (28 days) or fewer from onset, regardless of the health care setting. This includes patients who are transferred from the acute care setting to the post-care setting within the four-week time frame. For encounters after the four-week time frame in which the patient requires continued care related to the MI, assign the appropriate aftercare code, rather than a code from category I21. Otherwise, code I25.2, Old myocardial infarction, may be assigned for an old or health MI not requiring further care.

Z codes are often overlooked by providers in the office setting. TOAD is an abbreviation that helps providers quickly remember:

Transplants, Ostomies, Amputations/AIDS, Dialysis Status.

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.

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