"For outpatient or office visits, chronic conditions that require or affect patient care management should be coded. ICD-9-CM guidelines state:
Code all documented conditions that coexist at the time of the visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. Conversely, do not report conditions that do not require or affect patient care, treatment, or management.
Use the ICD-9-CM codes that describe the patient's diagnosis, symptom, complaint, condition, or problem.
Assign codes to the highest level of specificity. Use the fourth and fifth digits when ICD-9-CM deems necessary.
Do not code suspected diagnoses in the outpatient setting. Code only the diagnosis symptom, complaint, condition, or problem reported. Medical records, not claim forms, should reflect that services were provided for "rule out" purposes.
Code a chronic condition as often as applicable to the patient's treatment.
Chronic conditions that have an effect on a physician's medical decision-making may not be the reason the condition is treated or investigated during the visit. The main reason for the visit, or what was addressed during the visit, should be the first diagnosis listed on the CMS-1500 form. This is called the "first-listed diagnosis" and should agree with the sequence listed in the assessment of the patient's medical record."
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