Q: How would the following be viewed if it was included in a cardiology consult note:
Mr. Jones has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing post-conditioning (PPC). He is back in normal sinus rhythm (NSR). I would restart his warfarin if Dr. Smith will allow. Goal International Normalized Ratio (INR) is 2-3.
A: Because code assignment can be based on documentation of other physicians (e.g., consultants, residents, or anesthesiologists) that note meets criteria for a secondary diagnosis and doesn’t conflict with the attending physician. I can see where this case could be tricky, since it looks like the condition did not require further evaluation or diagnostic testing, and did not increase nursing care or increase the length of stay.
However, the cardiologist did want to restart the patient’s warfarin and if that occurred during this admission, then it would be treatment and make it a reportable condition. This could be a vulnerable claim if the physician does not document the atrial fibrillation in the discharge summary, with the need for continued follow up-care regarding the warfarin and/or if the paroxysmal atrial fibrillation is the only CC.
Editor’s Note:Sharme Brodie RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, Massachusetts, answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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