Neurosurgery Coding Alert

Question: Should I report a chronic condition if a patient presents for an acute condition? Louisiana Subscriber Answer: Yes, it is appropriate to report ongoing, preexisting conditions such as diabetes (250.0x) or Parkinson's disease (332.x) 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. This practice not only enhances medical records and coding accuracy but improves quality of care. Always list the primary reason for the visit first, followed by all 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. In either case, the complicating or preexisting 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.