Is that Afib...really paroxysmal?

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Not all atrial fibrillation is paroxysmal.

You know that.

But most people default to it without understanding the different definitions…or their implications.

And you’re about to find out why summarizing with “pAfib” is pointless.

First, what are the different definitions?

The different treatment strategies are outside of the scope of this newsletter…

But the most common problem I see is this: it is often ignored when someone is in (rate controlled) afib in the hospital while being labelled as paroxysmal afib.

However, if they truly have paroxysmal afib then that represents an acute <7 day episode and it needs to be evaluated and treated appropriately. Or…

maybe they don’t REALLY have paroxysmal afib. Maybe they have persistent Afib.

Also, as you can see, the “p” in “pAfib” doesn’t really narrow it down much. So, please avoid using that.

What are other implications?

Briefly, paroxysmal atrial fibrillation is NOT a CC, while the rest ALL are.

Not sure what a CC is? Check out my previous issue on it:

Below is my CC vs MCC vs neither chart for arrythmias:

Simply, diagnoses have more weight as they go from:

Not a CC/MCC → CC → MCC.

These have financial implications but many physicians and APP’s don’t care about hospital billing, so let’s talk about RAMI.

In brief, RAMI is a number that represents if people are dying at your hospital (or service line) more or less than expected.

You want to be less than 1.

I’ve seen “report cards” with individual physician RAMI scores.

You’d be surprised at the seemingly inconsequential diagnoses that can contribute to this (it is unique to each primary diagnosis). Something as simple PVC’s or a 1st degree AV block, diagnoses that you’d probably normally glance over, can be the difference between a patient expected to have died versus not.

So, generally document any arrythmia that you see, somewhere - even if it’s a basic interpretation of an EKG.

But what if they have a pacemaker?

These can be captured EVEN if they’re being controlled by the pacemaker.

So, make sure to mention WHY a patient has a pacemaker.

This often falls on the cardiologist, who, in my experience, need to be better at documenting this.

This is not the same for AICDs and VFib. However, it does count if they are coming in after a AICD shock for VFib or something similar.

Is Afib a secondary hypercoagulable state?

This a hot topic of debate because “secondary hypercoagulable state” is a CC.

But there is not universal agreement on whether atrial fibrillation with an elevated CHADS2VASC score requiring anticoagulation represents a secondary hypercoagulable state.

Coders cannot automatically capture this diagnosis just because someone is on anticoagulation. If you think it is, make sure to mention it.

I’ve given my opinion in informal conversations, but I need to discuss further with cardiologists to get their thoughts before I make a final determination.

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

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