Wiki Chronic Conditions

[Kristen Bensel]

I have a question that I am struggling finding solid documentation on, so I am hoping someone on here can point me in the right direction, or at least guide me to a solid answer.

If a patient is being seen by my provider for only one of the 4 chronic issues the patient has, even if the provider lists them all in the HPI, I still can't assign all four chronic codes if the provider isn't actually treating all four conditions right?

Example: Patients X has a DM2, HTN and AFib and CKD1 not related to DM2.. Patient presents today for her 6 month DM2 followup. Blood sugars are good, her insulin was adjusted last visit. She has a Cardiologist who is treating and monitoring her HTN and Afib. As well as a nephrologist who is treating her CKD1.
Assessment: E11.9, I10, N18.1, I48.91

My training has always directed me to only code the conditions that are being treated in this encounter. Therefore, the provider is ONLY treating the DM2 not the other three conditions, so i would only use the E11.9 on the encounter.

Even if the provider was to mention the medications the patient is on for these other chronics, I still couldn't use them right?

I am struggling to find solid documentation to give my provider to show that i can not assign those other codes since she isn't treating the patient for them.

Any help would be great. Thank you in advance!

Kristen Bensel CPC, CPMA

 

[thomas7331]

The ICD-10-CM book addresses your question in detail in the 'Official Guidelines for Coding and Reporting' at the beginning of the book. There are different guidelines for inpatient and outpatient. Assuming you're coding for the office, see section IV - Diagnostic Coding and Reporting Guidelines for Outpatient Services: under paragraph G: "List first the ICD-10-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.", and under paragraph J: "Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management."

Since a provider has to take into consideration patient comorbidities even if they are being managed by another physician, these can be said to 'affect treatment' even if the provider does not treat them directly or change the treatment plan at the encounter. So in your example I would code the additional conditions since the provider is documenting them for that encounter and commenting on their status. If they were just listed in the past history or as part of a patient problem list, I would not code them.

 

[Kristen Bensel]

Thank you for your response.