Coding Chronic Conditions During the Patient Journey

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Original story posted on: March 4, 2019

Coding of chronic conditions: Part 2

 This article addresses concerns regarding the coding of chronic conditions during a patient’s journey. The truth of the matter is that depending on your role in the coding process, your experience coding chronic conditions can differ greatly from that of others. As indicated in the first installment of this series, at the practice level, this often gets confused in the audit process or the leveling of evaluation and management (E&M) codes.

In risk adjustment or quality improvement activities, there is a more detailed focus on making sure all the reportable conditions are pulled out and documented. Unfortunately, in most medical practices, these same conditions can be missed in the reporting process.

Chronic conditions can be reported when they affect the physician’s thought process or decision-making. Often, understanding is simply not there as to why they can code the co-morbid conditions.

This is what makes it frustrating to those relying on the submission of those codes in the various quality programs out there.

It’s extremely important to code chronic co-morbid conditions when they are documented. Documentation can come from numerous places in the medical record. The patient’s history, the history of present illness (HPI), notations upon examination, etc. all can hold clues. It is not always just in the assessment and plan.

As stated often before, coders are not physicians. They cannot rely solely upon the physician’s documentation on the diagnosis process. Guideline 19 in the ICD-10-CM General Coding Guidelines states: “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Physicians have many documentation styles, and while we would all like every medical record encounter to follow an easy-to-read format, the bottom line is that this typically does not exist. This guideline was developed to address these types of situations.

It is vital to work with physicians on clinical documentation integrity (CDI) in order to produce the best clinical documentation for each patient’s journey, especially in light of transitions we are making to population-based health and advanced payment models.

The bottom line is that I often see that chronic co-morbid conditions are actually still reportable in today’s documentation, yet they are often missed in the physician practice. The reporting of these conditions is important so that the entire patient clinical journey is captured.

We, of course, would like the codes reported to be of the highest level of specificity possible. We always strive for greatness. In the absence of greatness, we can still supply an unspecified code. Your physicians may be requesting outside expertise on the condition via testing or referrals.

You want to make sure you take a hard look at the clinical documentation and code co-morbid conditions that influence documentation and depict the patient journey. This is the best way to capture the true clinical picture and validate the work that your physician has done, with the increased complexity of all document


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Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC

Rhonda Buckholtz is the vice president of practice optimization for Eye Care Leaders. She has more than 25 years of experience in healthcare, working in the management, reimbursement, billing, and coding sectors, in addition to being an instructor. She is a past co-chair for the WEDI ICD-10 Implementation Workgroup, Advanced Payment Models Workgroup and has provided testimony ongoing for ICD-10 and standardization of data for NCVHS. Rhonda spends her time on practice optimization for Eye Care Leaders by providing transformational services and revenue integrity for Ophthalmology practices. She was instrumental in developing the Certified Ophthalmology Professional Coder (COPC) exam and curriculum for the AAPC. Rhonda is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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