A 79-year-old patient is diagnosed with secondary hypercoagulable state and has a history of paroxysmal atrial fibrillation (AF) on anticoagulant maintenance. Does the provider need to link the secondary hypercoagulable state with the atrial fibrillation? What is the appropriate ICD-10-CM code assignment for secondary hypercoagulable state in this scenario?
Assign code D68.69, Other thrombophilia, for secondary hypercoagulable state. Secondary hypercoagulable state is specifically indexed to this code and includes secondary hypercoagulable state NOS.
Secondary hypercoagulable states are acquired disorders of thrombosis due to complex and multifactorial mechanisms. Patients with AF on chronic anticoagulant therapy may have an increased incidence of acquired hypercoagulable state. However, unless specifically documented by the provider, coding professionals should not assume the presence of a secondary (acquired) hypercoagulable state, in patients with atrial fibrillation. In this case, although the provider did not link the hypercoagulable state to the atrial fibrillation, secondary hypercoagulable state was documented by the provider.