Coding Chronic Conditions: An Acute Problem
Accurate ICD-10 coding requires understanding criteria for different clinical conditions.
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC
If you find coding perceived chronic conditions confusing, you’re not alone. Even seasoned coders have been known to get it wrong now and again. To work through it, it’s important for you to understand that it’s not enough to see in the documentation the words “ongoing,” “for the past 6 months,” “over the last several years,” etc. You may need to dig deeper to find the criteria surrounding a patient’s chronic condition. To drive the point home, let’s review some examples of different clinical conditions.
The National Headache Foundation estimates that 28 million Americans suffer from migraines. More women than men get migraines, and a quarter of all women with migraines suffer four or more attacks a month, 35 percent experience one to four severe attacks in a month, and 40 percent experience one no severe attacks in a month. Each migraine can last anywhere from four hours to three days or, in some cases, even longer.
Diagnostic coding classifies migraines by type:
- Hemiplegic migraines are a very serious and a rare type of migraine. The symptoms can range from concerning to debilitating, and the severity can vary from each episode. The patient may experience extreme pain and minor paralysis during one episode, and then experience minor pain with extreme paralysis during the next episode. Symptoms usually last from five to 60 minutes.
- Chronic migraines are classified by the International Headache Society as a migraine that occurs more than 15 days per month for at least three months.
- Persistent migraines last more than three months and occur daily from within three days of onset.
- Ophthalmoplegic migraines are also referred to as ocular migraines because the patient experiences pain around the eyes. It may cause dilated pupils and an inability to move the eyes without experiencing pain. These migraines are rare, and most commonly occur in children.
- Menstrual migraines are primarily caused by estrogen. Women experiencing estrogen level changes are more vulnerable to these headaches. The most common time for these migraines to occur is before, during, or immediately after menstruation or during ovulation.
- Abdominal migraines are very rare in adults and mostly affect children between the ages of 5 and 9. They are very hard to diagnose because the patient may only experience pain in the abdomen without having a headache. Often, children do not know how to express themselves and it’s hard for them to understand what is happening.
Example: The physician’s documentation states the patient has been suffering ongoing migraines for several years and they are tension type. In this example, the patient actually has tension type headaches, not chronic.
Because chronic migraines are classified by the International Headache Society as occurring more than 15 days per month for at least three months, you can see why you would need more information than just documenting “the past several years.”
Otitis media is usually painful and patients have symptoms of redness in the eardrum, pus in the ear, and a fever. Acute otitis media is the most common type of ear infection, occurring in the middle ear space, behind the tympanic membrane. In some cases, symptomatic treatment (over-the-counter pain relievers, eardrops, etc.) is used without the use of antibiotics. In other cases, antibiotics such as Amoxicillin are prescribed. According to the National Institutes of Health, three out of every four children experience an ear infection by the time they are three years old. For many children, it’s a recurrent issue with more than one-third of children experiencing six or more episodes by age seven. It’s the second most common childhood disease, with upper respiratory infections coming in first.
Otitis media with effusion:
- Build up of fluid in the middle ear without signs and symptoms of acute infection
- May be caused by viral, upper respiratory infections, allergies, or exposure to irritants
- Will not usually benefit from antibiotic treatment
Example: Patient presents for otitis media follow-up visit. He was previously treated one month ago for the same condition, same ear, and now presents for another case of otitis media. He suffered a similar episode over two years ago.
According to the American Academy of Otolaryngology-Head and Neck Surgery (AOA-HNS), there are specific criteria to be met to designate this condition as chronic:
- Acute – Acute onset
- Persistent – Relapse within one month of treatment
- Recurrent – Three or more episodes of acute otitis media within six to 18 months
- Chronic – Persistent recurrent
Based on this, the patient is considered to have persistent otitis media, not chronic.
Sinusitis is inflammation of the sinuses, occurring from a viral, bacterial, or fungal infection. Most sinus infections are caused by a virus. Other causes are allergies, structural issues within the nasal cavity, pollutants, or a weak immune system. Sinusitis affects an estimated 35 million people, with close to 16 million office visits a year.
Example: A patient presents for sinusitis that has been ongoing for the past 11 weeks. She seems to get no relief and she presents today feeling like she has not recovered. She is requesting another round of treatment.
This patient would be considered subacute, according to AOA-HNS criteria (volume 137, No. 3S, September 2007): Acute is defined as less than four weeks, subacute is four to 12 weeks, and chronic is more than 12 weeks, with or without acute exacerbation. When there are four or more acute episodes per year the condition is considered recurrent acute. This also aligns with the Centers for Disease Control and Prevention’s (CDC) overview of a sinus infection, “Acute bacterial sinusitis can last up to 4 weeks and subacute bacterial sinusitis can last 4 to 12 weeks, occurring less than 4 times a year … Chronic sinusitis typically lasts more than 4 weeks and occurs more than 4 times per year.”
When you understand the criteria for different clinical conditions, you are less likely to latch onto simple terms and assume clinical significance. Work with your physicians to keep them on the same page, as you work towards common goals of compliant documentation and coding.