2025 ICD-10-CM code I48.91
Unspecified atrial fibrillation.
Medical necessity for services related to atrial fibrillation is dependent upon the individual patient's clinical presentation and the specific treatment or management provided.Documentation must support the need for the services rendered, correlating them to the patient's signs, symptoms, and diagnosis.
Clinicians diagnosing and managing atrial fibrillation are responsible for accurate documentation of the type of AF based on patient presentation and diagnostic workup. This includes reviewing ECG findings, patient symptoms, and medical history to assign the appropriate ICD-10-CM code.
In simple words: This code signifies an irregular heartbeat where the upper chambers of the heart (atria) beat out of sync with the lower chambers (ventricles). The exact nature of this irregular heartbeat (atrial fibrillation) is not specified in the medical record.
This code is used when the patient presents with atrial fibrillation, but the physician does not specify the type (e.g., paroxysmal, persistent, chronic) in the documentation.It indicates an irregular and rapid heart rate caused by abnormal electrical activity in the atria.
Example 1: A patient presents to the emergency room with palpitations, shortness of breath, and dizziness.An EKG reveals atrial fibrillation. The physician does not specify the type of AF in the documentation.I48.91 is used., A patient with a history of hypertension reports feeling their heart racing.The physician diagnoses atrial fibrillation but doesn't document the specific type. I48.91 is used., During a routine check-up, an EKG incidentally reveals atrial fibrillation in an asymptomatic patient. No further details about the specific type are noted. I48.91 is used.
Documentation should include evidence of atrial fibrillation, such as EKG findings, physical exam findings (e.g., irregular pulse), and patient-reported symptoms.If the physician determines the type of atrial fibrillation (paroxysmal, persistent, chronic/permanent), this must be clearly documented to support the use of a more specific code.
- Payment Status: Active
- Specialties:Cardiology, Internal Medicine, Family Medicine, Emergency Medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office, Outpatient Hospital, Ambulatory Surgical Center, and other places where cardiac care may occur