# Clarification on coding comorbidities



## s_harris14 (Jul 8, 2015)

Hello! 

I am looking for clarification to make sure I am following the coding guidelines correctly.

My physician is a neurointerventional radiologist and treats patients with neurovascular conditions. Our most common treated diagnoses are stroke, cerebral aneurysm, cerebral & spinal vascular malformations, cerebral thrombosis and cerebral & spinal arterial dissections. Note: the physician does have a clinical practice and follows patients in the clinic on a rotational basis (i.e. 3 months, 6 months, 1 year, 2 year, etc) with repeat radiology imaging at most visits. 

Should I code comorbidities, specifically diabetes and hypertension, in addition to our primary diagnosis when they apply? And should these comorbidities be coded in addition to the primary diagnosis for each encounter of the primary dx?

We are not directly treating these comorbid conditions - their PCP or another specialist is managing medications and/or other treatments. However, these diagnoses in particular do affect our management/treatment and the physician does address at each visit the status of these conditions (controlled, not controlled, etc). If they are noted to be uncontrolled, the physician will recommend that the patient make an appointment with their PCP to control the condition. I.e. uncontrolled hypertension and/or diabetes are of importance to a patient with an unruptured aneuyrsm, moderate to severe vascular disease, or a history of stroke. 

Am I following the guidelines correctly by coding these comorbidities with the primary diagnosis when they affect or alter management and/or treatment of the primary diagnosis? 

Thank you!


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## cherene (Jul 14, 2015)

Yes, you are following the ICD-9 guidelines!

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.

I struggle with getting this point across as well....
Hoping this helps 

Cherene


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## s_harris14 (Jul 16, 2015)

Thank you so much Cherene! I really appreciate your help and support! 

Have a great day,
Stephanie


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