Part B Insider (Multispecialty) Coding Alert

Published on Thu Sep 15, 2005 PDF

Hint:  If the condition is irrelevant to treatment, leave it off your claim

Recognizing chronic conditions is crucial to choosing your most specific diagnosis code--a must for payor reimbursement. Here's everything you need to know about properly coding chronic conditions.

1. Select Codes Based On Medical Relevance

Just because a patient has a chronic condition--a condition that has persisted over a long period of time--that doesn't mean you should code it every time the patient comes in. Only report it if it's relevant to the service provided, says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, PA.

Example 1: A patient with high cholesterol (272.0, Pure cholesterolemia) arrives with a closed fracture of the collar bone (810.x, Fracture of clavicle). He isn't currently on any medication. The physician treats the fracture without manipulation (23500, Closed treatment of clavicular fracture; without manipulation). If the doctor confirms the cholesterol level wasn't medically relevant, only code the broken collar bone.

Pitfall: If your physician reports high cholesterol along with the fracture, don't immediately discount the cholesterol diagnosis. Check with your doctor to see if the cholesterol affected his treatment options. For instance, he may have had to consider it when prescribing medication.

Example 2: A diabetic patient presents with a closed fracture of the collar bone. The diabetes may put the patient at increased risk of infection and affect the physician's ability to choose steroids as an anti-inflammatory. In this case the chronic condition--diabetes (250.x, Diabetes)--does affect the physician's treatment options, so you should code for it.

Tip: If your physician uses a superbill, ask him to only code for those diagnoses that are medically relevant, whether it's because they affect care or because the patient has two conditions with similar symptoms and the physician must determine which is causing the current problem.

2. Know The E/M Documentation Codes

One place to look for documentation of a chronic condition is in the history of present illness (HPI) section of the E/M report.

Example: Your physician specifically questions the patient about her diabetes (250.xx), pulmonary edema (514, Pulmonary congestion and hypostasis) and high blood pressure (401.x, Essential hypertension)--all of which are chronic according to the documentation--as part of his history taking.

Note: Check your payer guidelines. While most payors and experts tell you to choose and stick to either the 1995 or 1997 guidelines, HGSAdministrators, the Part B carrier for Pennsylvania, says you may use the 1997 guidelines for "status of chronic conditions" even if you use the 1995 guidelines for other services. (View this advice on the "Frequently Asked Questions" page available at www.hgsa.com/cgi-bin/faqmanager.cgi?toc=faq.)

Logic: The 1997 Documentation Guidelines for E/M Services require the medical record to describe at least four elements of the present illness or "the status of at least three chronic or inactive conditions" for an extended HPI. The 1995 guidelines don't mention chronic conditions, explains Suzan Hvizdash, CPC, medical auditor for University of Pittsburgh Physicians, department of surgery in Pennsylvania.

Protect yourself: Experts claim there is little risk in following the 1997 guidelines even if you use the 1995 guidelines for everything else.

But if you're stricter than the rules, you'll have little trouble making it through a Medicare audit, Hvizdash points out.

Note: Proper documentation will also help you differentiate between management of stable chronic conditions and preventive medicine services. If the physician reports that the patient presented for a yearly visit, you're less likely to be coding a chronic condition than if the physician states the patient presented for a "follow-up," Hvizdash says.

3. Keep Track Of The Most Common Conditions

Eighty-seven percent of Medicare beneficiaries reported at least one chronic condition in a 2002 beneficiary survey. Translation: Chances are high you code for chronic conditions on a regular basis. Some of the most common chronic conditions include the following:

• 250.xx--Diabetes

• 272.0--Pure cholesterolemia

• 290-319--Mental disorders

• 401.x--Essential hypertension

• 428.x--Heart failure

• 496--Chronic airway obstruction, not elsewhere classified

• 530.81--Esophageal reflux

• 585.x--Chronic kidney disease (CKD), note: CKD requires a fourth digit as of Oct. 1

• 714.0--Rheumatoid arthritis

• 715.xx--Osteoarthritis and allied disorders

• 733.0x--Osteoporosis.

Watch out: Chronic conditions may require frequent check-ups which don't require the physician's presence.

Example 1: A patient presents for a blood sugar log review for type II uncontrolled diabetes, performed by a nurse in accordance with the patient's plan of care.

Solution: Report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) for the service, Falbo says.
The diabetes code should be 250.02 (Diabetes mellitus; type II or unspecified type, uncontrolled).

Example 2: A patient presents for a blood pressure (BP) check, taken by an RN following the plan of care established by the physician for hypertension, offers Falbo.

Solution: For the BP check, again report 99211, says Falbo.

For the diagnosis, you'll need more details for the appropriate code. Depending on your documentation, 401.1 (Essential hypertension; benign) may be appropriate for the hypertension.

Important: There is no cheat sheet for coding chronic conditions--you need to look for them on a case-by-case, visit-by-visit basis, says Hvizdash. Example: High blood pressure may be a chronic condition for a patient who then makes some lifestyle changes that bring his blood pressure into the normal range.

4. Read Documentation To Separate Condition From Symptom

Remember that the same complaint may be a chronic condition in one patient and a symptom of a condition in another--it's all in the documentation, says Hvizdash.

Headache Example 1: Patient A arrives for a follow-up of her frequent migraines. The doctor documents that the patient's headaches are well-controlled by medication. This is a chronic condition coded with 346.x (Migraine).

Headache Example 2: Patient B arrives complaining of a headache which the physician concludes is the result of acute sinusitis (461.x; Acute sinusitis). The headache in this case is a symptom of an acute condition.

Bottom line: Accurate documentation of chronic conditions is important because it allows you to choose the most specific diagnosis code, counsels Hvizdash. Choosing the correct code for your claim supports the medical necessity of the procedure you report, making it less likely your payor will ask to review your documentation, she adds.

Next time a report lands on your desk and reveals an ailment that could be a chronic condition, don't automatically code for it. Be sure the problem is relevant to the treatment and that it truly is a condition rather than a symptom of something else.