What is Chronic Atrial Fibrillation, Anyway?
By Erica Remer, MD, FACEP, CCDS, ACPA-C
The American College of Physician Advisors’ CDI Committee (disclosure: I am Chair) has published materials on numerous CDI topics. Each set of materials consists of a document detailing the points that a physician advisor should be aware of enabling them to educate their medical colleagues, and another downloadable document of a CDI tip for dissemination to the medical staff with pointers aimed at the clinician.
We are currently revising the tip on atrial fibrillation and flutter, and I found some interesting updates for you.
In 2023, the American College of Cardiology and American Heart Association published clinical practice guidelines on the diagnosis and management of atrial fibrillation (link to article here). For our and my committee’s purposes, the important update was the definitions of the types of atrial fibrillation (AF).
AF is the most common sustained dysrhythmia, which is characterized by disorganized, chaotic wiggling of the upper chamber/s of the heart causing irregularly conducted beats in the ventricles. It is clinically significant because patients seek medical attention, and it is associated with increased risk of stroke, heart failure, and death.
Paroxysmal AF terminates within 7 days or less of onset. It usually does not require intervention. It often is recurrent and intermittent.
Persistent AF is atrial fibrillation which is continuous and lasts for at least 7 days. It requires intervention to convert to normal sinus rhythm. It may recur. The article recommends that if a patient starts off with persistent AF, they should continue to be characterized as persistent even if the pattern of the AF subsequently becomes intermittent and “paroxysmal.”
Long-standing persistent AF is persistent AF that lasts for more than 12 months. The patient and provider have not yet given up the hope that someday this patient may be converted into normal sinus rhythm.
Permanent AF is persistent AF of some duration wherein the provider and patient make a shared decision to abandon efforts to convert the patient into a normal rhythm. There is no inherent difference in the character of the AF; it is just a therapeutic choice. These patients are often given medication long-term to control the rate of their AF and anticoagulation to reduce the risk of stroke or other issues from blood clots.
The new guidelines advise that the expression, “Chronic AF” is historical and should no longer be used. They explain “it has been replaced by the “paroxysmal,” “persistent,” “long-standing persistent,” and “permanent” terminology.” In an American Hospital Association Coding Clinic from 2019, guidance for the diagnostic statement of “chronic persistent atrial fibrillation,” was given that the coder should only use I48.1, the code prior to 2020 for persistent AF because “chronic atrial fibrillation is a nonspecific term” that could be referring to that laundry list of AF.
We’ll come back to this in a few moments.
When revising the materials, we delved deeply into the use of “history of” in the context of AF. As we know, providers and coders have different understandings of what “history of” means. To a coder, it means “old, resolved, in the past, no longer present.” To a provider, it means, “the past medical history includes,” and they do not really make a mental distinction between historical conditions and chronic conditions. The ICD-10-CM code used for verbiage of “history of AF,” Z86.79, is titled Personal history of other diseases of the circulatory system.” Can’t get more vague than that, and it bundles in with “history of” heart failure, coronary artery disease, or aortic aneurysm.
It is disconcerting to a provider to use verbiage indicating a current condition if it is not currently manifesting. This action will require explanation to them. They need to understand that if a patient has had AF in the past and they are still receiving any kind of work-up or treatment for it presently, the patient should be diagnosed with some type of AF. Compare it to diagnosing hypertension in a patient on antihypertensives whose blood pressure is 100/54. They still have hypertension, albeit chronic and controlled, not a “history of.”
On rate control for recurrent short-lived, self-terminating AF = paroxysmal AF. On antiarrhythmic to prevent recurrence of AF which required cardioversion after several months = persistent AF. What if the patient is on anticoagulation for AF, but they are not sure what the duration or type of AF it was, and you can’t access their records? That may be a situation where documenting “chronic AF, type unknown” would be clinically appropriate.
I do not recommend using “chronic AF” indiscriminately. Persistent, long-standing persistent, and chronic AF are all comorbid conditions or complications (CCs) whereas unspecified and paroxysmal AF are not. Using “chronic AF” for all AF could be interpreted as fraud or abuse, an attempt to capture a CC when it isn’t warranted.
Another point to teach your providers is descriptive diagnoses, although they feel like they are being specified, often result in an unspecified code. “Atrial fibrillation with a rapid ventricular response” and “new-onset AF” convey urgency and clinical significance to the practitioner, but to the coder, they mean I48.91, Unspecified atrial fibrillation. In the case of the new-onset AF, there may be no more specificity to be had yet, but the former term may have opportunity to specify.
The last addition to our materials relates to atrial fibrillation as a potential sepsis-defining organ dysfunction. Clinicians are aware that new-onset AF may be heralding serious pathology, such as sepsis or diabetic ketoacidosis. The literature supporting this stance can be found here.
ACPA has many excellent benefits for the physician advisor member including the CDI resource materials (https://www.acpadvisors.org/). I strongly recommend you/your physician advisor check us out.