Neurology & Pain Management Coding Alert

Question: May I appropriately report a chronic condition if a patient presents for an acute condition?

Missouri Subscriber

Answer: Yes, you may report ongoing, pre-existing conditions such as diabetes (250.0x) or Parkinson's disease (332.x) if the patient presents for a separate, acute condition but only if the chronic condition's presence is relevant to or affects treatment for the acute condition. This practice not only enhances medical records and coding accuracy but improves quality of care.

Always list the primary reason for the visit first, with all medically significant diagnoses listed subsequently. The existence of these "extra" diagnoses may justify the need for additional clinical evaluation or diagnostic procedures, or they may affect the evaluation and treatment of the acute condition that prompted the visit. In either case, the complicating or pre-existing condition may warrant a higher-level E/M service than would otherwise be necessary.

The complexity and number of coexisting conditions dictate how detailed an examination is necessary and the complexity of medical decision-making, and recording the additional diagnoses will help support E/M coding.