Revenue Cycle Insider

Know when a stable chronic condition still belongs on the claim.

Should you report a patient’s hypertension at every office visit? What about diabetes, chronic kidney disease (CKD), heart failure, or chronic obstructive pulmonary disease (COPD) when the physician does not make any changes to treatment?

These questions come up frequently in outpatient coding. A chronic diagnosis does not have to be newly diagnosed or actively changing to be reportable. At the same time, you cannot simply carry every condition on the patient’s problem list onto every claim.

The distinction comes down to whether the condition continues to coexist at the time of the encounter and requires or affects patient care, treatment, or management.

The FY 2026 ICD-10-CM Official Guidelines for Coding and Reporting specifically address chronic diseases, stating that 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. The guidelines also instruct you to code documented conditions that coexist at the time of the encounter and require or affect patient care, treatment, or management.

Start With the Reason for the Encounter

Before deciding whether to report a chronic condition, determine what happened during the encounter.

Review the assessment and plan, medication management, orders, monitoring, and other documentation rather than relying solely on the problem list.

For outpatient coding, the ICD-10-CM Official Guidelines instruct you to code all documented conditions that coexist at the time of the encounter and require or affect care, treatment, or management. You should not code conditions that were previously treated and no longer exist.

That means a chronic diagnosis can remain reportable even when it is stable.

For example, a patient with hypertension may come in for an unrelated complaint. If the physician reviews the patient’s blood pressure readings, continues the antihypertensive medication, and documents that hypertension remains controlled, the condition is still being managed.

The fact that the physician did not increase or decrease medication does not automatically make the diagnosis irrelevant.

Recognize When a Stable Condition Still Counts

One of the biggest misconceptions is that a chronic condition must be unstable, worsening, or actively treated with a medication change before you can report it, but this isn’t ICD-10-CM guidance.

Consider a patient with type 2 diabetes who presents for a routine follow-up visit. The physician documents that the diabetes is controlled, reviews the patient’s glucose readings, confirms continuation of the current medication regimen, and schedules a follow-up.

You can report E11.9 (Type 2 diabetes mellitus without complications), as the condition remains active and is part of the patient’s ongoing care.

Similarly, a patient with hypertension whose medication is continued and whose blood pressure is documented as controlled may still support I10 (Essential (primary) hypertension).

Takeaway: The absence of a medication change does not by itself mean the condition should disappear from the claim.

Separate Active Conditions From Historical Conditions

You should also distinguish an active chronic disease from a condition that no longer exists.

For example, suppose a patient had pneumonia six months ago and has completely recovered. The physician does not discuss ongoing pneumonia, treatment, or residual effects.

You should not continue reporting the acute pneumonia diagnosis simply because it appears in the patient’s historical records.

The ICD-10-CM Official Guidelines specifically state that you should not code conditions that were previously treated and no longer exist. A history code may be appropriate when the historical condition affects current care or treatment.

This distinction becomes particularly important when an electronic health record (EHR) automatically carries diagnoses forward.

Look Beyond the Problem List

The problem list can be useful, but it should not become a substitute for reviewing the encounter documentation.

Suppose the patient’s problem list contains conditions like type 2 diabetes, hypertension, CKD, and hyperlipidemia.

During the day’s visit, the physician discusses diabetes and hypertension but does not mention CKD or hyperlipidemia anywhere in the assessment, plan, or other relevant documentation.

Instead of assuming that every problem-list diagnosis belongs on the claim, determine whether the physician documented the condition as coexisting and whether it required or affected care, treatment, or management during the encounter. The ICD-10-CM Official Guidelines emphasize reviewing the entire record to determine the reason for the encounter and the conditions treated.

If documentation is insufficient and clarification would affect code assignment, follow your organization’s compliant query process.

Look for Part 2 next month, with more guidance on distinguishing the current encounter’s reporting from past conditions and reporting in compliance with official guidelines.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor