Neurology & Pain Management Coding Alert

Question: A patient came to our office for a follow-up visit because of her sleep apnea. She is obese and has hypertension. We’re not treating those conditions, although they could be causes of the obstructive sleep apnea.  Our physician documents the obesity and hypertension and lists them as billable diagnoses. Should we include these on our claim, or can we only bill for the obstructive sleep apnea since that’s the condition we’re treating?

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Answer:  If your physician has noted the obesity and hypertension and that they could be related to the patient’s sleep apnea, he probably is taking those factors into consideration when he plans the patient’s treatment. Because of this, you can report the hypertension and obesity as additional, coexisting diagnoses since they affect patient care. List obstructive sleep apnea as the first diagnosis on your claim and reason for your physician’s treatment of the patient.

Support: The ICD-9 official guidelines verify that you can approach the situation this way. The guidelines state, “List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.”

Additional guidelines direct you to “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist.” If the patient loses weight and is no longer obese, for example, you won’t include that diagnosis on future claims. In addition, if the provider documents the patient’s specific BMI, the ICD-9 indicates “Use additional code to identify Body Mass Index (BMI) if known (V85.0-V85.54)”.