Wiki "code also" or " buddy codes" required assessment?

[krystyna_ebingergil@ihacares.com]

morning, need help please!! as a new auditor I'm having difficulty with validating "code also" code that providers are choosing due to the coding convention guidelines. However the problem is when they chose these codes there is no assessment done. for example Hypertension I10 with nicotine dep, cigarette, uncomp F17.210. Social hx shows patient is a smoker. is this enough or do we have to have an assessment of these "buddy codes" as well.
any feedback is greatly appreciated. Thank you

 

[thomas7331]

I don't believe there's any requirement in the ICD-10 guidelines that the conditions associated with the additional codes be assessed by the provider at that encounter in order to be reported. Although the primary codes should reflect the reason for the visit and any other conditions that are treated or affect treatment, it's my understanding that when the ICD-10 code instruction states to report an additional code, the additional code should be included whenever that information is available in that record.