Internal Medicine Coding Alert

Hint:  If the condition is irrelevant to treatment, leave it off your claim

Recognizing chronic conditions is crucial to choosing your most specific diagnosis code--a must for payer reimbursement. Here's everything you need to know about properly coding chronic conditions.

1. Select Codes Based on Medical Relevance

Just because a patient has a chronic condition--a condition that has persisted over a long period of time--that doesn't mean you should code it every time the patient comes in. Only report it if it's relevant to the service provided, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, Pa.

Example 1: A patient with high cholesterol (272.0, Pure cholesterolemia) arrives with a closed fracture of a rib (807.01, Closed fracture of one rib). He isn't now on any medication. The physician treats the fracture without manipulation (21800, Closed treatment of rib fracture, uncomplicated, each). The doctor does not address the cholesterol level because it isn't medically relevant, so he only codes the broken rib.

Pitfall: If your physician reports high cholesterol along with the fracture, don't immediately discount the cholesterol diagnosis. Check with your doctor to see if the cholesterol affected his treatment options. For instance, he may have had to consider it when prescribing medication.

Example 2: A diabetic patient presents with an acute extrinsic asthma attack (493.02). The diabetes may put the patient at increased risk of infection and affect the physician's ability to choose steroids as an anti-inflammatory. In this case the chronic condition--diabetes (250.x)--does affect the physician's treatment options, so you should code for it.

Tip: If your physician uses a superbill, ask him to code only for those diagnoses that are medically relevant, whether it's because they affect care, because the patient has two conditions with similar symptoms and the physician must determine which is causing the current problem, or because the physician addressed multiple problems during the same visit.

2. Know the E/M Documentation Rules

One place to look for documentation of a chronic condition is in the history of present illness (HPI) section of the E/M report.

Example: Your physician specifically questions the patient about her diabetes (250.x), pulmonary edema  (514, Pulmonary congestion and hypostasis) and high blood pressure (401.x, Essential hypertension)--all of which are chronic according to the documentation--as part of his history taking.

Note: Check your payer guidelines. While some payers and experts may tell you to choose and stick to either the 1995 or the 1997 guidelines, HGSAdministrators, the Part B carrier for Pennsylvania, says you may use the 1997 guidelines for "status of chronic conditions" even if you use the 1995 guidelines for other services.

Logic: The 1997 Documentation Guidelines for E/M Services require the medical record to describe at least four elements of the present illness or "the status of at least three chronic or inactive conditions" for an extended history of present illness (HPI). The 1995 guidelines don't mention chronic conditions, says Suzan Hvizdash, CPC, medical auditor for University of Pittsburgh Physicians in Pennsylvania.

Note: Proper documentation will also help you differentiate between management of stable chronic conditions and preventive medicine services. If the physician reports that the patient presented for a yearly visit, you're less likely to be coding a chronic condition than if the physician states the patient presented for a "follow-up," Hvizdash says.

3. Keep Track of the Most Common Conditions

Records show that 87 percent of Medicare beneficiaries reported at least one chronic condition in a 2002 beneficiary survey.

Translation: Chances are high that you code for chronic conditions regularly. Some of the most common chronic conditions include the following:

• 250.x--Diabetes

• 272.0--Pure cholesterolemia

• 290-319--Mental disorders

• 401.x--Essential hypertension

• 428.x--Heart failure

• 496--Chronic airway obstruction, not elsewhere classified

• 530.81--Esophageal reflux

• 585.x--Chronic kidney disease (CKD) (CKD requires a fourth digit as of Oct. 1)

• 714.0--Rheumatoid arthritis

• 715.x--Osteoarthritis and allied disorders

• 733.0x--Osteoporosis.

Watch Out: Chronic conditions may require frequent checkups that may not always require the physician's presence in the exam room 

Example 1: A patient presents for a blood sugar log review for potential medication adjustment for type II uncontrolled diabetes, performed by a nurse in accordance with the patient's plan of care.

Solution: Report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, five minutes are spent performing or supervising these services) for the service, Falbo says. The diabetes code should be 250.02 (Diabetes mellitus without mention of complication; type II or unspecified type, uncontrolled). Be sure that the documentation shows the medically necessary reason why the practice performed the blood sugar log review.

Example 2: A patient presents for a blood pressure (BP) check to assess whether the medication recently initiated is working, The BP is taken by an RN following the plan of care established by the physician for hypertension, Falbo says.

Solution: For the BP check, again report 99211, Falbo says. For the diagnosis, you'll need more details for the appropriate code. Depending on your documentation, 401.1 (Essential hypertension; benign) may be appropriate for the hypertension

Important: There is no cheat sheet for coding chronic conditions--you need to look for them on a case-by-case, visit-by-visit basis, Hvizdash says. For example,  high blood pressure may be a chronic condition for a patient who then makes some lifestyle changes that bring his blood pressure into the normal range.

4. Read Documentation to Separate Condition From Symptom

Remember that the same complaint may be a chronic condition in one patient and a symptom of a condition in another--it's all in the documentation, Hvizdash says.

Headache example 1: Patient A arrives for a follow-up of her frequent migraines. The doctor documents that the patient's headaches are well-controlled by medication. This is a chronic condition coded with 346.x (Migraine).

Headache example 2: Patient B arrives complaining of a headache that the physician concludes is the result of acute sinusitis (461.x, Acute sinusitis). The headache in this case is a symptom of an acute condition.

Bottom line: Accurate documentation of chronic conditions is important because it allows you to choose the most specific diagnosis code, Hvizdash says. Choosing the correct code for your claim supports the medical necessity of the procedure you report, making it less likely your payer will ask to review your documentation, she adds.

The next time a report lands on your desk and reveals an ailment that could be a chronic condition, don't automatically code for it. Be sure the problem is relevant to the treatment and that it truly is a condition rather than a symptom of something else.