Oncology & Hematology Coding Alert

Question: On an E/M claim, is it appropriate to include diagnosis codes for every problem a patient has, even if the physician is just renewing prescriptions or just noting a problem that another physician follows, like hypertension or asthma?

Virginia Subscriber

Answer: For physician service claims, you only need to report diagnoses relating to current conditions/complaints that the physician is evaluating and that support the service you report. You don’t need to report a history of a condition or one currently under control if it doesn’t affect that day’s service.

Helpful: Section IV of the ICD-9-CM official guidelines applies to provider-based office visits. It includes these instructions:

"List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician."

"Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment."

To review the guidelines, go to www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf.