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.
- 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.
- 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.
- 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