ED Coding and Reimbursement Alert

Question: One of our providers is saying that we should always code chronic conditions as chronic conditions with exacerbation because chronic conditions always have the capability of exacerbating at any time. However, I believe you can only code a chronic condition as chronic with exacerbation at the time of a visit when the patient is presenting with that exacerbation. Which of us is correct?

Nebraska Subscriber

Answer: Both ICD-10 and the AMA in the CPT^® guidelines for the office/outpatient evaluation and management (E/M) codes view chronic illnesses with exacerbations in the same way:

“An acute exacerbation is a worsening or a decompensation of a chronic condition” (ICD-10 Guideline 1.C.10.a.1).

“Chronic illness with exacerbation, progression, or side effects of treatment [is a] chronic illness that is acutely worsening [or] poorly controlled” (CPT^® Guidelines for Office or Other Outpatient E/M Services).

From this, it seems clear that both guidelines distinguish between chronic conditions and chronic conditions with exacerbations.

While any chronic condition has the capability of exacerbation, you cannot assign a diagnosis to a chronic condition before an exacerbation, just as you cannot assign a diagnosis to an acute condition that has yet to happen. In other words, a chronic condition is either stable or it is in a state of exacerbation, and you should assign a code that reflects whichever condition is current at the time of the patient encounter.