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Atrial Fibrillation

Chief Complaint

The patient is a 56 year old male with intermittent episodes of irregular heart beat that causes mild shortness of breath and a general sense of malaise, but no chest pain. He has been evaluated over the past year and has documented recurring episodes of atrial fibrillation recorded on a Holter monitor. He is being treated for ongoing benign hypertension with an ACE inhibitor. Questioning reveals that he has not been taking his medication as prescribed and more as he feels the need. On previous visits to this office related to his hypertension he continues to admit noncompliance.

History

  • The patient is otherwise in good health with no significant history of coronary atherosclerosis, angina or valvular disease.

Assessment

  • Intermittent atrial fibrillation
  • Ongoing benign hypertension
  • Poor BP medication compliance

Documentation Tips

  • ICD-9 was able to capture the condition of atrial fibrillation but did not capture if it was paroxysmal, persistent or chronic. ICD-10 does capture those concepts assuming nature of the atrial fibrillation is documented in the record
  • The concept of benign vs. malignant hypertension in ICD-9 has been dropped in ICD-10 in favor of one code for essential or primary hypertension
  • In ICD-10 there is now the ability to capture underdosing to indicate a problem with non-compliance with medications

Comparison of Current ICD-9 Code and Illustrative ICD-10 Codes

ICD-9-CM

427.31 Atrial fibrillation

401.1 Benign essential hypertension

ICD-10-CM

I48.0 Paroxysmal atrial fibrillation

I10 Essential (primary) hypertension

T46.5X6D Underdosing of other antihypertensive drugs, subsequent encounter