This page addresses follow-up questions and additional information pertinent to our webinar
Is it Clinically Significant? Applying Additional Diagnosis Guidelines.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: How would the condition described as acute and chronic be coded when there is no combination code option to capture both the acute and chronic aspect of the condition? For example, Patient with known chronic gastritis admitted for acute gastritis treatment.
A: Guidelines state to code both, when separate subentries exist in the Index, and sequence the acute code first. So, for our example, the acute gastritis code K29.00 is assigned first and code K29.50 is assigned as secondary diagnosis for chronic gastritis.

Q: Can the code for BMI be assigned as a secondary diagnosis from the nursing documentation?
A: Yes, guidelines allow assignment of BMI documented by the nursing staff when the associated diagnosis such as obesity is documented by the provider. Refer to OCG Section I.B.14 for a complete list of codes that can be assigned based on other clinicians’ documentation.

Q: What codes are considered Social Determinants of Health?
A: SDOH codes represent the non-medical factors that influence health outcomes such as food insecurity, problems related to education or literacy, problems related to employment, inadequate housing, and things like financial insecurity or even loneliness. They are found in Chapter 21 and include codes from Z55 through Z65.

Q:  Per Coding Clinic, “…it is appropriate to code congenital anomalies, such as Mongolian spots, when identified by the provider since they can have implications for further health care needs.” However, ICD-10-CM coding guideline states to “Assign codes for conditions that have been specified by the provider as having implications for future health care needs.” If Mongolian spots is documented in the physical exam but the provider does not explicitly state that the condition has implications for future healthcare needs, should Mongolian spots be coded?
A:  We recommend using caution when assigning a code for Mongolian spots when the provider has not indicated it is a significant condition or that it will require care in the future. While Coding Clinic is an official coding resource, the coding guidelines take precedence over Coding Clinic advice. Additionally, the addition of code Q82.5, Congenital non-neoplastic nevus, with a principal diagnosis from category Z38 will increase the MS-DRG and could give the appearance of upcoding of the condition and its significance are not well documented. There is no impact to the APR-DRG grouping.

Q: I have a question – on the webinar you don’t address preop – EKGs – PVCs and PAC- found or noted by the pre-op anesthesia note or noted on the Pre-op EKG, days prior to the admission. Sometimes that information is brought into the current admission…. Any thoughts? The dx are getting coded so they are picked up, yet when we point out that it should be POA Coding does not want to change them.​
A:  The diagnoses would need to be documented as meeting the MEAT criteria on the current visit or encounter.  For example, in the pre-anesthesia note, the documentation would need to indicate that the diagnosis was taken into consideration for anesthesia risk to meet the criteria.  This would be on a case-by-case basis and the POA assignment would be reliant on the documentation.  If the documentation supports, as you mentioned, that the diagnosis was from prior documentation (such as an H&P) the coder could determine that the condition was present on admission if still relevant and being treated.

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