Know the Guidelines for Reporting Chronic Conditions, Part 2
Dive deeper into exploring when stable chronic conditions belong on the claim. Coders may have trouble deciding when a chronic but stable condition belongs on a claim. Does it affect treatment and management? Was it documented in the most recent encounter? Does documentation support reporting? The FY 2026 ICD-10-CM Official Guidelines for Coding and Reporting specifically address chronic diseases, stating that you may code chronic diseases treated on an ongoing basis 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. Find out the specifics on when reporting makes sense. Apply Specificity When the Documentation Supports It Once you determine that a chronic condition is reportable, make sure you code to the highest level of specificity supported by the documentation. For example, when the physician documents a specific stage of chronic kidney disease (CKD), report the code for that documented stage rather than an unspecified CKD code. For example, if the physician documents “chronic kidney disease, stage 3a,” report N18.31 (Chronic kidney disease, stage 3a (GFR 45-59 mL/min)). If the physician documents “chronic kidney disease, stage 3b,” report N18.32 (Chronic kidney disease, stage 3b (GFR 30-44 mL/min)). You should not assign the CKD stage yourself based solely on laboratory results. The physician’s documentation must support the diagnosis and stage being reported. Likewise, if a patient has diabetes with a documented complication, do not automatically default to E11.9. For example, when you report E11.22 (Type 2 diabetes mellitus with diabetic chronic kidney disease), you should also assign the applicable CKD code to identify the stage, such as N18.31 or N18.32, when documented. Follow the Tabular List instructions for additional coding. Capture Conditions That Affect Management Sometimes the chronic condition is not the primary reason for the visit but still affects the physician’s work. For example, a patient presents for follow-up of osteoarthritis. The physician also reviews the patient’s chronic heart failure, confirms that the patient remains stable on current medications, and continues the treatment plan. The heart failure may be reportable because it affects the care and management provided during the encounter. Depending on the physician’s documentation, a specific heart failure code may be required (for example, I50.32 [Chronic diastolic (congestive) heart failure]). Do not select a heart failure type or acuity that the physician has not documented. This distinction is particularly important with heart failure because ICD-10-CM provides separate codes for acute, chronic, and acute-on-chronic heart failure. Code assignment should reflect the acuity documented by your physician. Avoid Coding Conditions That Are No Longer Active The opposite mistake is carrying a diagnosis forward simply because it has appeared repeatedly in previous encounters. Consider this example: A patient was treated for acute bronchitis several months ago. At today’s visit, the physician documents that the infection has resolved and does not address bronchitis or ongoing symptoms. Do not report J20.9 (Acute bronchitis, unspecified). The patient no longer has that condition. If the physician documents a relevant history that affects today’s care, a history code may be appropriate instead. The ICD-10-CM Guidelines distinguish current conditions from historical conditions and provide guidance on reporting personal history codes when the historical condition has an impact on current care or influences treatment. Handle Chronic Conditions During Diagnostic Visits You can also report a chronic condition as an additional diagnosis when a patient receives diagnostic services. For example, a patient undergoes cardiac imaging because of chest pain and also has documented chronic hypertension that affects the physician’s management of the encounter. So, for this example, you would report the following codes on the claim: Rationale: Report the chest pain first when it is the reason for the diagnostic service, followed by the hypertension when it is clinically relevant to the encounter and meets the reporting requirements. The same principle applies to therapeutic services. You should identify the condition chiefly responsible for the service and then report other documented conditions that meet the requirements for additional reporting. Watch for Documentation That Creates Confusion Several phrases can make chronic condition coding less straightforward. Pay attention to documentation that includes the following wording: Important: “Stable” does not necessarily mean “historical” — a chronic disease can be stable and still require ongoing care. “History of,” however, may indicate that the physician considers the condition historical rather than current. When the distinction affects coding and the documentation is unclear, a compliant query may be appropriate. Check Your Chronic Diagnosis Before You Report It Before assigning a long-term diagnosis on an outpatient claim, ask yourself the following questions: These questions can help you avoid two opposite problems: dropping legitimate chronic conditions from claims and automatically carrying inactive conditions forward. Keep the Focus on the Current Encounter Chronic condition coding is not a matter of counting how many times a diagnosis appears in the patient’s chart. Your job is to determine whether the condition is documented as current and whether it requires or affects care, treatment, or management during the encounter. The FY 2026 ICD-10-CM Official Guidelines for Coding and Reporting give you an important foundation: You may report chronic diseases treated on an ongoing basis each time the patient receives care for those conditions. At the same time, you should not continue to code conditions that no longer exist. When you take the time to distinguish an actively managed chronic disease from a historical or merely carried-forward diagnosis, you produce a claim that more accurately reflects the care provided and the physician’s documentation. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
