Forum - Questions & Answers

Sep 2nd, 2014 - Tchang.ccscodingspecialist

How to code A-fib with bradycardia?

1. Toproal XL 100 mg q evening for Bradicardia. HR 88, Pt denies chest pain or palpitations. Physical Heart exam reveals
Irregular Rhythm, no murmurs or fiction rubs noted. Condition appears stable. Recommend f/u per PCP discretion and prn
Cardiology.
2. Warfarin 4 mg per schedule for Atrial Fibrillation. Physical Heart exam reveals HR 88, Irregular Rhythm, no murmurs or fiction
rubs noted. Condition appears stable. Recommend f/u per PCP discretion and prn Cardiology.
6. Torsemide 20 mg/40 mg alternating dosing daily and Ramipril 10 mg daily for CHF. Congestive Heart Failure: Patient's
current medications are consistent with active treatment. Currently utilizes beneficial Cardiac Rx's such as Diltiazem ER. No
peripheral edema upon exam and Diuretic is providing efficacy to promote QOL & ADL's. Patient states shortness of breath
when walking up steps and when walking several blocks. Physical Chest exam reveals cough, audible scant wheezes and
rhonchi to left lung base. Pt has mild shortness of breath with exam when speaking in full sentences. Recommend f/u per PCP
discretion and prn Cardiology.
Past medical history of coronary artery bipass surgery, sinus surgery, vertigo, and gastric ulcer.

Documentation from the patient's assessment.

I was told to code A-fib, 427.31 only and not also 427.89 for Bradycardia. Is this correct and if it is please explain why/ how I only code A-fib.

Thank you!



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