Wiki Chronic vs acute condition

[coder5254]

I took the PCCM course and was taught if the physician did not document "acute", you coded unspecified or chronic. Acute could not be coded unless documented by physician. Does anybody have any authorative documentation to support this conclusion? Thanks

 

[007CPC]

I know that when the documentation says Acute and Chronic the coder should code Acute as primary/principal and Chronic as secondary. Depending on the condition, conventional notes and instructional notes add nonessential modifiers in both the alphabetic and tabular: which leaves the question of what specific disease you are coding that requires special sequencing instructions not given in the alphabetic and tabular.

 

[FTessaBartels]

Unspecified may = acute

I was actually taught the opposite of you. In the absence of the physician stating "chronic," code acute or unspecified. In some diagnoses code descriptions "acute" and "unspecified" are the same code.

Think about this for a minute ... "acute" can mean that it is immediately occuring, a disease of sudden onset, or short-term. In effect, it is the "thing" that brings you to the doctor. So, unless the physician states that a condition is chronic, you'd have no choice but to code as acute (or unspecified, if that is a separate diagnosis code.)

F Tessa Bartels, CPC, CPC-E/M

 

[ARCPC9491]

I agree with Chad and Tessa.

 

[coder5254]

Chronic vs acute

I was taught to code unspecified or chronic, not acute unless specified by physician. I understand the reasoning why you would want to use acute, pt presents with signs/symptoms and doctor diagnoses sinusitis. But he did not document acute sinusitis, so by coding acute sinusitis you have added to the physician diagnosis. In this case I would code unspecified. I can't find any documentation to support either way, and most of the other coders I work with were taught the same. Never code acute unless documented.

 

[007CPC]

I was taught to code unspecified or chronic, not acute unless specified by physician. I understand the reasoning why you would want to use acute, pt presents with signs/symptoms and doctor diagnoses sinusitis. But he did not document acute sinusitis, so by coding acute sinusitis you have added to the physician diagnosis. In this case I would code unspecified. I can't find any documentation to support either way, and most of the other coders I work with were taught the same. Never code acute unless documented.

Then again anything could apply in the corporate coding context.

 

[ARCPC9491]

http://www.cdc.gov/nchs/data/icd9/icdguide.pdf

There's the link to the official icd9 guidelines ... it specifically states that unspecified should be used when the medical record is insufficient to assign a more specific code ... as mentioned above, most "unspecified" include "acute"...

Hope that helps you ...