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