Coding for I48 Atrial Fibrillation and Secondary Hypercoagulable state D68.69 ?

drksingh

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Hello Coding masters,
Here is another one for discussion.

Is it allowed to code for both Atrial Fibrillation I48.x and Secondary hypercoagulable state aka Other thrombophilia D68.69 ?

Optum has a guidance document out there (see link) that describes the relationship.

The ICD-10 doesn't have additional code requirements for A. fib or any direct Coding clinic guideline to support such a clinical relationship otherwise.

Any thoughts?
 

thomas7331

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Not sure I understand what you're asking here - the Optum guidance you've posted here spells it out pretty clearly. Just because it's not required as an additional code doesn't mean that you aren't allowed to code it, if so indicated and supported by the documentation. If it meets the definition of a reportable additional diagnosis per the ICD-10 guidelines, then it would be allowed and appropriate to code. There aren't any excludes notes between these codes that would indicate that they shouldn't be coded together.
 

drksingh

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I agree if the physician described the new diagnosis, coders are obligated to code for it up to the specificity. It is something like that the physician would want to say since there is an arrhythmia, and diabetes and hyperlipidemia and increased risk due to age and other factors, the risk score is high hence I want to consider secondary hypercoagulable state hence code for D68.69. Physicians are free to write and describe the diagnosis they feel appropriate and coders code for it.

I am wondering if D68.69 is not an HCC diagnosis, would they want to describe the risk in the same way? A.fib is already an HCC and the treatment is anti-coagulation, and hence it takes into account the risk of thromboembolism.

We don't see this D68.69 coded very often by Primary care providers, right? Maybe this is document is circulated by Optum to attract an HCC code, and Optum is advising physicians on such relationship with evidence from the medical literature and let this guidance document float around. I find this as misinformation for getting to an HCC in a creative way.

We would have to consult an Electrophysiologist & Hematologist to make a determination whether this relationship is always clinically valid. In my personal opinion, I don't see this as a right HCC coding relationship, unless otherwise, the patient has primary thrombophilia due to inherited blood coagulation disorder that makes the hypercoagulable state risk for the patient.
 

thomas7331

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Some of your questions are outside my scope as I am trained as a coder and not as a clinician. I'm not able to comment on what you are speculating here about this being "misinformation" - I'd leave it to a physician to read this and decide when and whether it is appropriate to document this condition. But the coding information given on page 2 is accurate, in my opinion. And I think you're correct that this isn't a code you encounter very often in Primary Care. In fact, in the last 10 years or so of working multispecialty coding, including Cardiology, I don't recall ever having encountered documentation where I used this code.

The discussion on how providers can better capture patients conditions in documentation in order to more accurately reflect higher levels of risk generally is handled by someone with a specialty and training in Clinical Documentation Improvement (CDI). In my experience, those individuals usually have nursing license in addition to a background coding. Perhaps someone on this forum that experience may post an answer for you here, but in the years that I've been active on AAPC I haven't seen much activity by CDI specialists. I think that is an area that is usually handled more by inpatient facility coders, so I might suggest looking to AHIMA rather than AAPC as a better source for feedback on questions like this.
 

fwnewbie

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I believe you should code both Afib and the thrombophilia. The risk with Afib is clots forming in the atria because there is incomplete emptying and stagnant blood = clotting. Add to this an underlying clotting problem and the risk just gets higher. The word "secondary" is a clue that the risk of clotting is present regardless of the heart rhythm. Check the lab results for the proof of thrombophilia.
 

drksingh

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@fwnewbie That would be primary thrombophilia if present. I am referring to Other thrombophilia (secondary hypercoagulable state) D68.69
 

fwnewbie

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Regardless of what is causing the thrombophilia, A-fib does not cause a disorder within the platelets-it allows the stagnant blood in the atrium to clot.
If there is no lab that shows what is causing the secondary hypercoagulable state, then all you have is the default code.
According to the Optum article, every patient with A-fib is hypercoagulable but since the state isn't documented as to type, go with default.
Just so you are aware, I am an RN without coding experience. Proceed at your own risk. :)
 

drksingh

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@fwnewbie Are you suggesting that it is okay to code A. Fib with the secondary hypercoagulable state with just clinical risk documented by the provider?
 

fwnewbie

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No. Provider needs to state "pt has a blahblahblah" and that condition should be coded as either a named condition or as a NEC/NOS secondary hypercoag state.
 

fwnewbie

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I think my response is confusing so sorry about that! Clinical risk in and of itself is not codeable in my opinion - it's a vague reference at best.
I would delve deeper into the pt hx for that secondary h-coag. When did it first appear and was there an exact dx of the type of disorder mentioned by provider or pathologist. If a pathologist (who is a doctor) diagnoses a specific blood disorder of coagulation, I would feel confident that I would be coding with the greatest specificity if I used that code with the A-fib.
 

drksingh

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Agreed. All that a physician writes cant be a true diagnosis. Least we know tomorrow a physician will say hyperlipidemia leads to MDD with mania in his best clinical judgment, and can we believe that & code it out?
 
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If still unsure of coding A-Fib w/ Secondary Hypercoagulable state(D68.69). In my PCP office, we use the D68.69 code regularly and note the reason, such as A-fib, PE, Chronic DVT, etc. We also note in the in the documentation if they are using medication to prevent recurrence of clots. This was initiated for HCC coding as recommended by Optum-UHC.
 

drksingh

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Optum article is not an ICD-10 guideline. Prophylaxis of a disease condition is not equal to a confirmed diagnosis. Suspected conditions cannot be reported as confirmed diagnoses in outpatient settings.

Anti-coagulation given for prophylaxis is not the same as a chronic condition. Follow the rules and stay out of potential "upcoding".

Read the following:

Inherited and Secondary Thrombophilia; Kevin P. Cohoon and John A. Heit Originally published14 Jan 2014 https://doi.org/10.1161/CIRCULATIONAHA.113.001943Circulation. 2014;129:254–257.

Wintrobe’s clinical hematology text (chapter 55 - Thrombosis and Antithrombotic Therapy - see table 55.1)
it does not mention anywhere that atrial fibrillation as a risk factor or associated with the secondary hypercoagulable state at all, while other known diseases, such as antiphospholipid syndromes, estrogen use, pregnancy, and active cancer are listed as risk factors.

As per Optum article, every female who is above 65 years of age will have a higher risk factor for Sec. Hypercoagulable state (using CHADVasc_score) that is not true at all. It is a theoretical concept and such patients do not have other blood clotting disorders. Virchow's triad is an early 19th-century concept.

If provider has a written assessment from a Hematologist or a cardiovascular specialist or the Electrophysiologist, then only you can validate that the secondary hypercoagulable state actually exists and is beyond just "risk of" that clotting state.

Confirmation of a diagnosis and workup is required to prove that you are not just upcoding based on an HCC that is available. If D68.69 was not an HCC no one will bother to write any extra word about it.

Be very careful what you choose to do.
 

KellyLR

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I think my response is confusing so sorry about that! Clinical risk in and of itself is not codeable in my opinion - it's a vague reference at best.
I would delve deeper into the pt hx for that secondary h-coag. When did it first appear and was there an exact dx of the type of disorder mentioned by provider or pathologist. If a pathologist (who is a doctor) diagnoses a specific blood disorder of coagulation, I would feel confident that I would be coding with the greatest specificity if I used that code with the A-fib.
Agree that documented as "clinical risk" warrants further documentation for solid code reporting. But I'm in favor for code D6859 based on what was read here until I see what was further determined to be coagulation etiology.
 
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Would anyone support the following statement: Afib with associated secondary hypercoaguable state due to afib, HR controlled. Monitor HR?

This is a blanket statement always documented along with Afib by a vendor and this vendor bills D68.69 and they are one of the very few providers billing for this code.

Any opinions are greatly appreciated!
 

drksingh

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There can not be a blanket statement unless there is a coding concept in the ICD-10 manual. Secondary hypercoagulable state is not associated with A.Fib. I am sure the vendor is aware of the risks of upcoding.
Ask them to show if this is written in the ICD-10-CM manual that you have to have an additional code whenever A. Fib is coded? There you have an answer.
 
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There can not be a blanket statement unless there is a coding concept in the ICD-10 manual. Secondary hypercoagulable state is not associated with A.Fib. I am sure the vendor is aware of the risks of upcoding.
Ask them to show if this is written in the ICD-10-CM manual that you have to have an additional code whenever A. Fib is coded? There you have an answer.
Thank you for your response. I have had doctors push back to me saying that afib is a hypercoagulable state, which I agree, and therefore is a secondary hypercoagulable state. Does anyone have any guidance on how to push back on the doctors so I have additional fuel to add when speaking with the vendor? I really appreciate all opinions here as this will aid my discussion with leadership.

Do you or anyone else have additional information what classifies a secondary hypercoagulable state? Is that in the Optum guidance mentioned above or some other place?
 

drksingh

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The provider treating the patient has to dictate that the secondary hypercoagulable state exisits in the patient at the time of outpatient visit. It cannot be assumed. He/she will have to do note some work-up to substantiate the diagnosis with some MEAT to the diagnosis. It is not a assumed relationship. OPTUM article is not ICD-10 guideline. And there is no assumed relationship here.

FYI, the cardiac devices for treatment of A.Fib are approved so that the patient can be taken of anti-coagulation. If underlying reason was Secondary hypercoagulable state, then such devices will never work. A Fib increase risk of stroke, but it does NOT mean that A. Fib causes Sec. Hypercoagulable state.

I hope CMS takes this HCC away, then no one will be bothered to code it anymore.
 

drksingh

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Medical literature on this topic, such as a very relevant research article from Mayo clinic (Inherited and Secondary Thrombophilia published in 2014) and Wintrobe’s clinical hematology text (chapter 55 - Thrombosis and Antithrombotic Therapy ref. table 55.1), do not mention atrial fibrillation as a risk factor or the underlying cause of the secondary hypercoagulable state, while other known diseases, such as antiphospholipid syndromes, estrogen use, pregnancy, and active cancer are listed as risk factors.
 

drksingh

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Would anyone support the following statement: Afib with associated secondary hypercoaguable state due to afib, HR controlled. Monitor HR?

This is a blanket statement always documented along with Afib by a vendor and this vendor bills D68.69 and they are one of the very few providers billing for this code.

Any opinions are greatly appreciated!
This vendor is upcoding. DO NOT fall for this trap.
 
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