A: With the publication of Coding Clinic article “Clarification: Reporting Additional Diagnoses in Outpatient Setting,” which was released in Third Quarter 2021 and applies to discharges on or after September 20, 2021, we would not recommend coding hypertension if only mentioned in the past medical history, even if the patient is on medication. To report this code, there must be documentation from the provider that the condition affects the care and management for the current encounter. In a clinic setting, that means the provider must document that the condition was addressed. In a hospital outpatient encounter, all provider documentation may be used for reported diagnoses, so conditions listed in the impression by a radiologist or pathologist should be coded as well as any conditions documented by the anesthesiologist that impact the ASA score when anesthesia is administered.
Q: Should the long-term use of insulin code be used for Type 1 diabetics?
A: Patients who are type 1 diabetics require insulin for survival, so adding code Z79.4, Long term (current) use of insulin, does not offer any additional information and is redundant. While there is no specific guideline stating that code Z79.4 cannot be coded with codes in category E10 for type 1 diabetes, you will notice that this category of codes does not have the “Use additional code” instructional notes that other diabetes categories (E09, E11, E13) have.
Q: How do I know if a newborn condition requires future care?
A: It is the physician’s responsibility to indicate that a newborn condition requires future care. In the ICD-10-CM Official Guidelines for Coding and Reporting, section I.C.16.a.6:
Note: The perinatal guidelines listed above are the same as the general coding guidelines for “additional diagnoses,” except for the final point regarding implications for future health care needs. Codes should be assigned for conditions that have been specified by the provider as having implications for future health care needs.
Q: In single path coding, can codes from the pro-fee account just be copied over to the facility outpatient account?
A: Haugen Consulting Group does not recommend copying diagnosis codes directly over from the physician’s claim to the hospital claim because there is more documentation available for coding on the hospital record than the pro-fee record.
Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer
Director of Coding Quality & Education
Kristi is a Director of Coding Quality & Education with more than 25 years of industry experience; she is responsible for the development of web-based, instructor-led, and webinar training materials; conducting training in ICD-10-CM/PCS and CPT; and performing DRG and APC audits. Kristi has an extensive background in coding education and consulting and is a national speaker and published writer on topics related to ICD-10 and CPT coding and code-based reimbursement. She has designed and developed training programs for inpatient and outpatient hospital-based coding, with a focus on vascular interventional radiology, interventional cardiology, orthopedics, and obstetrics.