Primary Care Coding Alert

Remember: If the condition has no bearing on treatment, leave it off your claim

Just because a patient has a chronic condition doesn't mean you should code it every time the patient comes in.

Here's some sound advice from expert coders on when to -- and when not to -- code chronic conditions.

Let Medical Relevance Guide Your Code Choice

Only report a chronic condition -- a condition that has persisted over a long period of time -- if it is relevant to the service provided, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, Pa.

Example 1: An established patient with high cholesterol (272.0, Pure hypercholesterolemia) arrives with a wood splinter in his forearm. He is not on any medication. After making an incision with a scalpel over the wound site, the FP grabs the end of the splinter with a pair of tweezers and removes it. The doctor does not address the cholesterol level because it isn't medically relevant.

On the claim for this scenario, report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the procedure. Remember to attach ICD-9 code 913.6 (Superficial injury of elbow, forearm, and wrist; superficial foreign body [splinter] without major open wound and without mention of infection) to 10120 to prove medical necessity for the encounter.

Pitfall: If your physician reports high cholesterol along with the splinter removal, 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: An established patient with type II diabetes presents with trouble breathing. The FP performs a level-three E/M service, during which he diagnoses acute extrinsic asthma. The FP prescribes medication and sends the patient home. In this scenario, the diabetes may put the patient at increased risk of infection and affect the physician's ability to choose steroids as an anti-inflammatory.

The chronic condition does affect the physician's treatment options, so you should code for it. On the claim, report the following codes:

--99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem- focused examination; medical decision-making of low complexity) for the E/M.

--493.02 (Extrinsic asthma; with [acute] exacerbation) linked to 99213 to represent the patient's asthma.

--250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) linked to 99213 to represent the patient's diabetes.

Try this: If your physician uses a superbill, ask him to code only for those diagnoses that are medically relevant, whether it is because:

--the diagnoses affect care;

--the patient has two conditions with similar symptoms and the physician must determine which is causing the current problem; or

--the physician addressed multiple problems during the same visit.

Know Your 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.xx), 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 elements.

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.

Tip: 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.