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Q:  Can you please clarify if you can code a condition listed in the past medical history if there is a medication for it on the medication list? For example, would you code a condition like hypertension if they were on meds but weren’t given that medication during an outpatient encounter?
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

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.

6 Comments

  1. Kathy

    Kristi – If we code based on requiring provider acknowledgement of disease/condition, it would seem that a lot of codes that would fall into HCC hierarchy would be missed. This seems contradictory to what has been published historically.

    Reply
    • kkluglein

      Hi Kathy,

      The coding advice published in Coding Clinic, 3rd Quarter 2021 supports coding guidance for risk adjustment (RA) coding. Officially, CMS instructs all submitted RA diagnosis codes be “supported” by medical record documentation, but they do not define what constitutes “support”. MEAT and TAMPER criteria were created to help with this definition. HCG does not recommend coding only from a list of comorbid conditions. The expectation is that patients will see a provider for management of the condition, but if/when this does not occur, the documentation should show how the active comorbid condition is impacting their care to show support of the RA condition. The HCC methodology is based on reporting of certain chronic conditions within a calendar year. If a chronic condition was documented but not addressed and did not impact the treatment for the current encounter, it should not be coded. It is expected that the condition would be addressed in another encounter within the same calendar year, in which case, it would be reportable and satisfy HCC reporting. Coding Clinic, 2nd Quarter 2022, pages 30-31, clarifies the advice in the 3Q Coding Clinic article and addresses its impact on HCCs.

      Reply
  2. sherry.corsello

    Hi Kristi,

    Thank you for your response on “Clarification: Reporting Additional Diagnoses in Outpatient Setting.” This “clarification” from coding clinic has given us more confusion than clarification. Pertaining to your response, the hospital stay is different than a clinic setting for the physician documentation requirement? Any response would be appreciated. Thank you!

    Reply
    • kkluglein

      Hi Sherry – Based on the Coding Clinic article about coding for reporting of additional diagnoses in the outpatient setting, this guidance applies to all outpatient health settings. The guidance states that is inappropriate to assign codes based solely on diagnoses noted in the history, problem list and/or medication list. The provider must document how the chronic condition affected the care and management of the patient for the encounter. For clinic visits, this generally means coding only the assessment since the provider does not always specifically address each condition notes in the history or problem list. For outpatient surgery records, there is more documentation, including the anesthesiologist’s assessment, which lists conditions that will impact the patient’s ASA score (anesthetic risk). While there may be conditions listed on a preoperative H&P in the history, problem list, and/or medication list that are not otherwise addressed by the provider writing the H&P, those conditions may be noted in the anesthesia assessment and they will be monitored during surgery. In such case, it would be appropriate to report the conditions since there is documentation they impacted care.

      Reply
  3. olga

    z codes (2) -did you miss status presence coronary stents Z95.5 on purpose?

    Reply
    • kkluglein

      Hi Olga – Thank you for your question. In the webinar “Taking a Second Look at Secondary Diagnoses,” Z code example #3 is for a stroke patient who has a history of coronary stent placement. Since the presence of a coronary stent presents a cardiovascular risk, we would recommend assigning code Z95.5 (Presence of coronary angioplasty implant and graft) as a secondary diagnosis. Slides 44 and 45 in the slide deck have been updated to reflect this change.

      Reply

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