# Substantial documentation



## fritzta (Oct 6, 2008)

When abstracting diagnosis codes in a record and coding for something like Hypertensive Heart Disease and Chronic Kidney Disease, the relationship between the two must be stated in the documentation to use a code from the 404 category. My question is in regards to the documentation.  Is it sufficient for the relationship to be stated anywhere in the record, i.e previous dates of service/encounters, or must that documentation of that relationship be on the date of service being coded?


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## storturica (Oct 6, 2008)

Unfortunatly each date of service is looked at by Medicare as an individual visit. It must state it on that visit


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## fritzta (Oct 6, 2008)

Thanks I'm running in to a lot of scenarios where a patient has DM with renal manifestations. On some dates the manifestation is/are documented but others it is not. So a good rule of thumb is to only code exclusively for one date of service at a time.  Just kind of confusing, because when a doc sees a pt. on Tues and they have end stage renal disease due to DM, its not like that complication is going to disappear by Wed. when the doc sees the patient again.  Wouldn't not coding the same thing from one day to the next mess with HCC and DRGs etc?


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## FTessaBartels (Oct 7, 2008)

*INpatient or outpatient?*

Are you talking about subsequent visits in an inpatient setting?

F Tessa Bartels, CPC, CPC-E/M


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## fritzta (Oct 7, 2008)

Yes, these scenarios would be in a inpatient setting when charted diagnoses vary from one DOS to the next.  For example if Joe Smith was seen on day two of an inpatient stay and the doctor charted DM with renal manifestations and chronic kidney disease was the manifestation, is it o.k. to code 250.40 and the 585.9 on a date in the future (say day five) when the type of DM and the kidney disease is not mentioned or specified.  Or would I have to only code to what is documented in that note on that DOS, regardless of whether complications were mentioned in the past during the same hospital stay.  If so, does this differ from coding outpatient?


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## junebug1969 (Oct 8, 2008)

We actually have two questions going on here...
1. What are the requirements to code hypertensive heart disease with chronic kidney disease?
2. What are the requirements in coding diabetes with chronic kidney disease in an inpatient setting.

For question number 1, this is one of the few situations in which coders are supposed to code a relationship even if it is not specifically indicated as cause and effect in the medical record. Due to the nature of the process of hypertension and kidney disease, they are always to be assumed as related unless otherwise specified. So in other words, if the record states that a patient has hypertension and ESRD, the correct code assignment would be:
403.91
585.6
However, to code from the 404 category, the record would need to state that hypertensive heart disease (not just hypertension) along with chronic kidney disease. However, the cause and effect would still not need to be indicated in the medical record to use codes from this category. Just to clarify, hypertension and chronic kidney disease are always considered to be related.

The second question deals with diabetes and renal disease. In this case cause and effect needs to be documented. However, once it has been documented for an admission, you don't need to have it reiterated every day in order to code it as such. Many doctors don't rewrite every diagnosis on each day during an inpatient setting. Unless he would make a revision to the previous diagnosis (such as renal disease is found to be due to X), you have the prior documentation to allow you to code for the relationship between diabetes and renal manifestations. 

Hope this helps!


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## fritzta (Oct 9, 2008)

Thanks, I new that some relationships were implied. Sorry for using two different scenarios.  I was more concerned about documentation and whether the relationships needed to be documented every day or if earlier in the whole patient record was sufficient.  I would assume then, in an outpatient setting such as a doctor's office, each DOS needs to clearly state any relationships?


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## junebug1969 (Oct 12, 2008)

fritzta said:


> Thanks, I new that some relationships were implied. Sorry for using two different scenarios.  I was more concerned about documentation and whether the relationships needed to be documented every day or if earlier in the whole patient record was sufficient.  I would assume then, in an outpatient setting such as a doctor's office, each DOS needs to clearly state any relationships?



This is just an educated opinion... and I will gladly defer to anyone who has the coding convention that states otherwise. However, I believe that if you have access to the medical record, i.e. you're not coding from a billing company where you have limited documentation on patients, then you should code for these relationships. If a patient has ESRD that has been previously attributed to diabetes, then that relationship continues for all subsequent coding. 

Unless some other cause/effect has been indicated then you must code from what is documented, that the renal disease is caused from diabetes. Since you have access to the medical record, that will suffice as adequate documentation. As with inpatient coding, many doctors are not going to indicate those codes with each visit. In fact, if the patient comes in for the flu, it will likely not be on the encounter form. However, it still should be coded as those are conditions that affect the care and management of a patient. 

Regardless of setting, hypertension/renal disease are considered related and are coded as such.


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