While assigning diagnosis codes for chronic conditions may seem straight- forward, some confusion remains regarding which conditions should be coded in the outpatient setting.
Medical coders are responsible for assigning ICD-10-CM codes for all diagnoses made by a healthcare professional that affect the patient’s care. These codes tell a detailed story about the patient’s condition, provide a comprehensive summary for the payer, and help to create continuity of care between healthcare providers and settings. The first listed diagnosis explains the primary reason for the patient’s visit, but often it is the secondary codes that help to provide medical necessity for the services performed. Luckily, there are resources available to point coders in the right direction.
Know the Rules
The ICD-10-CM guidelines provide guidance on which codes are to be included on medical claims. There are two important guidelines which can be used when determining whether a code for a chronic condition should be assigned:
- Guideline I. states, “Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).”
Guideline IV.J. states, “Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.” These guidelines tell the coder which conditions should be coded: all documented conditions, including chronic diseases, which are present at the time of the encounter and that affect patient care, treatment, or management. In the outpatient setting, this may be a chronic illness the patient has had for many years that needs management or it could be a newly developed acute problem that requires care.
How to Decide?
When thinking about what might affect patient care or management, coders can use the acronym MEAT (monitoring, evaluating, assessing, and treatment) to help them decide which codes to assign. The MEAT acronym is often used in risk adjustment coding but can be used in any coding setting to help determine whether a condition has been addressed. Questions to consider are:
- Did the provider monitor signs and symptoms or disease progression or regression?
- Did they evaluate test results or the patient’s response to treatment?
- Did they assess the patient?
- Did they review tests or records or provide counseling?
- Did they treat the patient using medication or some other modality?
It’s important to note that not all the components of MEAT need to be satisfied; even just one component met can demonstrate medical necessity.
Consider Patient History
If a condition has been previously treated and resolved, it should not be coded as a current condition. However, the guidelines state that history codes may be used as secondary codes if the historical condition or a family history has an impact on the patient’s current care or if it influences treatment.
Personal history codes show that a patient no longer has a condition that requires treatment but may have the potential for recurrence and therefore should be monitored. Documenting and coding for personal history is valuable because having a history of an illness could alter the treatment ordered. Oftentimes facilities will develop guidelines regarding the capture of history and other status codes. Coders should always check with their facility for any internal policies regarding patient history.
The American Hospital Association’s AHA Coding Clinic recently published advice regarding the coding of chronic conditions in the outpatient setting. Its 2021 3rd quarter issue advises not to assign codes based solely on diagnoses noted in the history, problem list, and/or medication list, and that it is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter.
Simply stating in the past medical history that a patient has hypertension is not enough documentation to assign a diagnosis code for that condition. When reviewing the medical record, coders need to look for evidence that the condition, or its treatment, had an impact on the encounter. Was the patient’s hypertension monitored, evaluated, assessed, or treated? Did the provider state its significance to the encounter or show how it affected their medical decision making? The condition must be relevant to assign a code.
Consider the following example.
Case Example
A patient presents for outpatient surgery for a musculoskeletal problem. There is a documented history of anxiety in the past medical history, and the medication list shows that the patient is taking a prescription drug for the condition. With just that information alone, the coder should not assign a code for anxiety according to Coding Clinic® advice. However, if the provider had documented that the patient was anxious during the stay and that it was affecting their treatment, or that medications were adjusted or managed due to the patient’s anxiety, then the anxiety would be coded because the provider documented that the condition was relevant to the present encounter.
This Coding Clinic® advice is in keeping with the official coding guidelines, which instruct the coder to assign codes for all documented conditions that coexist at the time of the encounter/ visit and require or affect patient care, treatment, or management, and that chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).
Code With Confidence
While current guidelines and advice clearly instruct how and when to code for chronic conditions, it can still be difficult at times to determine whether a condition should be coded. But by following all available guidelines and applying MEAT criteria, coders can more confidently capture chronic conditions in the outpatient setting.
Reference:
[…] for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional […]
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