Archive for September, 2018

Coding/Reporting of Chronic Conditions

Posted by Samantha Serfass on September 18, 2018 in Blog, News

Coding/Reporting of Chronic Conditions


With so many patients having multiple chronic conditions and taking a plethora of medications for multiple conditions, we still seem to struggle as coders on what may or may not be considered a chronic condition?  You would think that this might be straight forward, however, we all struggle with determining what to code and what not to code.  First, let’s start by identifying what is considered a chronic condition.  In the dictionary, ‘chronic’ means having an illness persisting for a long time or constantly recurring.  Some synonyms of this are: constant, ceaseless, unabating, unending, persistent, and long-lasting.  Many coders, as we all know, have differing perspectives on this subject.

Something else to consider id if the facility you code for has their own in-house guidelines. Many facilities tend to have their own guidelines for how they want these secondary conditions reported.

Section IV of the guidelines has two components that assist to direct decisions regarding secondary diagnosis code assignment.

  • Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)
  • Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.


Here are some things to take into consideration when determining whether to report a diagnosis.


  1. Is this a current condition?  Documentation often makes this more difficult if it is not clear on whether a condition is resolved or if it is a simply in the patients’ history.  If it is resolved, it should not be reported.  Physicians often use “history of” when documenting conditions.  For example:  history of Congestive heart failure would mean that the patient used to have heart failure but has since undergone a heart transplant or other procedure and no longer has it.  However, if the patient is on medication chronically they have chronic congestive heart failure.
  2. Does this condition affect patient care or management?  I also tend to think that if medication/medications are being prescribed and or added, then the physician also would need to know what the patient medical conditions are and what medications the patient is currently taking so as to not cause an additional problem/s due to an adverse effect when making his/her determination.
  3. Is this a chronic condition that the patient receives ongoing treatment?  Per Coding Clinic 3rd Quarter 2007 pages 13 and 14 it states, “If there is documentation in the medical record to indicate that the patient has COPD, it should be coded.  Even if this condition is listed only in the history section with no contradictory information, the condition should be coded.  Chronic conditions such as, but not limited to, hypertension, Parkinson’s disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation.”


I was just speaking with a fellow coder the other day and we were debating regarding the condition asthma for example.  She said that she felt if she’s on albuterol inhaler but has not had any issues with her asthma in years that it probably shouldn’t be reported as a chronic condition but on the flip side, my response was that what if you were being seen in urgent care for something like bronchitis and while there you had an asthma attack.  Asthma even though you may not have issues with it is still present and could present itself in the right circumstances and should be considered chronic.

As coders, we review, investigate and paint a picture of the patients’ overall health condition.  It is our responsibility to be clear and concise when doing so and provide the highest level of specificity from the documentation one can provide.  Consistency is key in knowing what to report and what not to report.

Tonya Tucker, CCS, AHIMA approved ICD-10 CM/PCS approved Trainer

Internal Auditor/Educator

Digital Transformation in Healthcare – The Human Experience

Posted by Samantha Serfass on September 4, 2018 in Blog, News


Digital Transformation in Healthcare –

The Human Experience

Technology has changed the world as we know it in what seems like a blink of an eye, giving us endless opportunities and far reaching concepts. Technology has changed our lives for the better, but it has also uncovered unforeseen disruptors in many industries. Digitalization disruption has the potential to reshape markets faster than any force in history. One industry which promises gigantic advances in this rapidly changing landscape is healthcare.

The digital revolution has not only brought changes in the role technology plays in healthcare, it is changing how healthcare data is collected, processed, stored, analyzed and utilized. Health organizations throughout the country and the world are in the early stages of this digital transformation journey. Today, US hospitals are faced with improving the quality of healthcare and access to healthcare, controlling the costs of healthcare as life expectancy increases, providing services to the 76 million baby boomers as well as serving the increasing population.

The US spends more on healthcare per capita per year than any other nation, but it lags in outcomes. By focusing on improving population health, furthering the development of information and cultivating collaborative efforts globally, we will begin to see an improvement in outcomes. An already complicated and intricate industry with a multitude of stakeholders, is now having to rethink the way it delivers service. How can healthcare leadership, clinicians, front-line staff and technologist work together to help the effort within the four walls of our hospitals? Let’s look at four areas of focus that can transform the hospital culture, align perspectives and improve outcomes.

Increasing Patient Engagement

Patients want personalized healthcare. They want to be active participants on their path to improvement with a connection to their physician. It’s important to make interactions and encounters more human, communication among doctors, nurses and patients needs to be clear and consistent. Leveraging technology to extend contact with patients is one area healthcare organizations can improve patient engagement. Easy access to nurses and doctors through patient portals or live chat applications, and automated messaging appropriately timed and tailored to the patient’s treatment can help improve health outcomes.

Empowering Healthcare Teams

It is more important than ever for healthcare organizations to ensure skilled and competent resources are hired at every level. From patient access, ancillary services, patient care, to proper training and education – frequent skill audits can ensure all skill gaps are identified and corrected.  When selecting leaders, select professionals you can trust to do the right thing, allowing them to take ownership and be accountable for results.  Once you’ve conveyed the vision and provided them with the tools they need, give them an active role in developing a short-term business solution plan. This should be designed with improvement, deliverables and milestones in mind. Once they select their team, provide an environment where they can succeed. Nurture the team and monitor progress against those milestones. This will keep the team accountable for results. Expect mistakes and be prepared to reroute and redirect. This will signal trust to other areas within the organization changing and improving the organizational culture.

Optimize Clinical & Operational Effectiveness

As healthcare organizations prepare for digitalization, it’s critical to re-evaluate and optimize clinical and operational workflows.  There are many automated tools and methods accessible to collect workflow information, organize data, monitor usage and optimize activities. Examining bed tracking, transportation and supplies, accessibility to healthcare equipment, as well as procurement processes and procedures will help optimize clinical and operational workflows. Organizations need to implement smarter and faster clinical communication enabling clinicians and staff to spend more time collaborating treatment and taking care of the patient.

Transform the Care Continuum

Clinical care practices within highly complex healthcare systems require leaders to advance their way of thinking. Transitional care models can guide program development to facilitate the adoption of new processes. Direction needs to be driven by a leadership team and steering committee, and initiatives need to be clearly communicated to each department. Implement and track KPIs (Key Performance Indicators) to improve performance. Focus on maintaining high quality care across healthcare settings.  Provide a holistic, personal care approach and align and prioritize care initiatives. High maturity organizations focus beyond their four walls. This allows these organizations to promote self-awareness, flexibility, willingness to learn, creativity, decisiveness and improve effective communication.


Nina De Los Santos, PMP

VP Operation Delivery at Excite Health Partners