Medicare Compliance & Reimbursement

Question: We find the Medicare billing process a bit confusing and aren’t sure what to include on our claims pertaining to our beneficiaries’ diagnoses. When preparing a claim, should we enter the diagnosis code only for the condition the physician is treating? Or should we list all the current conditions that the patient is experiencing?

Ohio Subscriber

Answer: The answer to this question is open to interpretation. ICD-10 Official Guidelines, Section IV.J, tells you to “code all documented conditions that coexist at the time of the encounter/ visit, and that require or affect patient care, treatment or management,” and not to “code conditions that were previously treated and no longer exist.” It also tells you that you can use “history codes (categories Z80- Z87) … as secondary codes if the historical condition or family history has an impact on current care or influences treatment.”

This issue, then, revolves around whether the other conditions listed affect patient care or treatment. This may be up for interpretation based on your physician’s documentation. The provider will always consider all the patient’s conditions when deciding how best to treat or manage a specific condition, even though their documentation may not fully illustrate their decision-making process. So, encourage your provider to capture all the patient’s conditions that may impact patient management to make the documentation a true reflection of the medical decision-making involved in any given encounter and the medical necessity for the treatment program chosen for a specific patient.