Wiki Urgent Care Chronic conditions (as secondary codes)

[Sarah Ann]

Hello
Does the following make sense in the urgent care setting?

Coding managers are having us code only chronic conditions listed under the past medical history list(on the urgent care report) that match up to a medication on their list as secondary conditions even if no chronic conditions are mentioned in the HPI, or assessment.

Conversely if a chronic condition is mentioned in the HPI, or impression/assessment (for instance HTN) and they are not on any medications for HTN don't code at all.
I mean some diseases are managed/treated without medications.
Thank you!

 

[thomas7331]

Your managers may have their reasons for having you do this, but it is not really consistent with official coding guidelines. Per the official ICD-10 guidelines for outpatient services, you should "code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management". Conditions in history that have not been documented as requiring or affecting care should not be coded unless specific code descriptions state to list them in addition to the primary code.

You're correct that a disease can require or affect treatment without necessarily having a medication associated with it. And just because a medication is listed in the past history does not mean it is affecting treatment at the current encounter. It strikes me as a bit of a waste of coders' time to be trying to match medications with diseases in the history - that is not in the normal scope of a coder's role. In my opinion, coders should code conditions from what the provider has documented that they treated or considered during the encounter, not from past history or medication lists.