Gastroenterology Coding Alert

Question: Must we report the ICD-10 codes for all the current conditions that the patient has regardless of whether they are managed or treated during the observation stay? Do we only report conditions that the patients are on medications for — even if those are not managed or treated?

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Answer: It is appropriate to report ongoing, preexisting conditions such as diabetes or Parkinson’s disease if the patient presents for a separate, acute condition as long as the chronic condition’s presence is relevant to or affects treatment for the acute condition, or where it is appropriate to assess the status of those chronic problems. This practice not only enhances medical records and coding accuracy, but improves quality of care.

In black and white: “For outpatient claims, providers report the full diagnosis codes for up to 24 other diagnoses that coexisted in addition to the diagnosis reported as the principal diagnosis,” CMS says in Section 10.3 of Chapter 23 of the Medicare Claims Processing Manual. “For instance, if the patient is referred to a hospital for evaluation of hypertension and the medical record also documents diabetes, diabetes is reported as another diagnosis.”

Always list the primary reason for the visit first, followed by the remaining medically significant diagnoses. The existence of these “extra” diagnoses may justify additional clinical evaluation or diagnostic procedures, or they may affect the evaluation and treatment of the acute condition that caused the visit. The complexity and number of coexisting conditions dictate how detailed an examination is necessary and the complexity of medical decision-making.

If the patient is on medication for a particular condition that is in no way relevant to the current observation care, then most insurers would not require you to report it. For instance, if you see a patient for GERD and that patient has diabetes, a history of kidney failure, and is on eyedrops to treat a scratched cornea, you would likely report the code for GERD, followed by the diabetes, and then the kidney failure history. The corneal abrasion would likely not be addressed, nor would it be relevant to the GERD, and most insurers would therefore not require you to report it.

The other general reason to record ICD-10 codes for comorbidities is to capture the complexity of patients’ conditions for severity adjustment purposes. This is most immediately pertinent in the Medicare Advantage programs, where the premiums plans receive are risk-adjusted. However, the resource cost use, even for physicians who have been submitting quality data for PQRS (and now for MIPS), is affected by severity adjustment, so it plays a role even now in the Value Based Modifier applied to fee-for-service Medicare physician payments. Once CMS decides to “count” resource cost in the MIPS program, it is likely that precise ICD-10 codes capturing patient complexity will be important.