![]() Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance.2021 ICD-10-CM (Chapter 9: Diseases of the Circulatory System).ICD-10: I48.91 (If supported by documentation, a more specific code than 148.91 should be used.) Plan: Continue digoxin for AF and follow up in three months. Progress Note: Assessment: Atrial fibrillation, stable and controlled with digoxin. Take advantage of the Annual Health Assessment (AHA) or other yearly preventative exam as an opportunity to capture all conditions impacting member care.Note complications with an appropriate treatment plan. ![]() Document each diagnosis as having been monitored, evaluated, assessed and/or treated on the date of service.Ensure documents are signed and dated by a credentialed provider.Document legibly, clearly and concisely.Include patient demographics, such as name and date of birth, and date of service in all progress notes.The type of AF (paroxysmal, persistent, permanent or history of) should be documented consistently throughout the note to avoid unspecified codes that don’t fully define the member’s condition. Only one code may be assigned for a specific type of AF.Document in the note any current associated physical exam findings (such as irregular heart rhythm or increased heart rate) and related diagnostic testing results.In coding, "history of" indicates a condition is no longer active.Code I48.19, Other persistent atrial fibrillation, should be assigned. Chronic persistent AF has no widely accepted clinical definition or meaning. ![]()
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