Question Coding all documented conditions...


Lees Summit, MO
Best answers
ICD-10-CM coding guidelines instruct coders to accurately capture secondary dx as documented/addressed by the provider in the body of their note and A/P to the highest specificity. We are also instructed to code all documented conditions that co-exist at the time of the encounter/visit AND require or affect patient care, treatment or management. To me, these two directives are somewhat contradictory. A provider may document 10 or more diagnosis in their A/P without clearly identifying if some do actually affect patient care. Is documenting a co-existing condition the same addressing it? If the provider does not clearly document how a co-existing condition affects their treatment plan or level of MDM, it seems to me that leads the coder to make suppositions with regard to what is a pertinent secondary diagnosis and what is not. I am a specialty coder currently working pro-fee pulmonary hospital charges. In this age of productivity quotas, it takes an inordinate amount of time to code what I see as an excessive list of co-existing dxs my providers document. How am I to determine what has an impact on the patients current care or influences treatment to code correctly AND efficiently?

Besides querying the provider for clarification, any advice you can offer will be greatly appreciated.

Thank you in advance,
Erin E
Your provider(s) may be in the vanguard who already understand the importance of reporting chronic conditions to payers as the payment models continue to migrate to quality of care/risk adjustment payment. Regular reporting of chronic conditions to "tell the patient's story" is slowly but surely replacing the traditonal profee model of coding only what is needed to establish medical necessity for a specific episode of care. Even if the additional diagnosis codes don't affect the level of the code selected, reporting comorbidities communicates the severity of the patients overall condition. Sounds like your provider is starting to think in a risk adjusted frame of mind but just needs some help with CDI to better document how it factored into the MDM.
We are having the same struggles with pertinence and documentation that emeskina talks about in her post. While I agree with talton0206 that reporting of the chronic conditions helps to explain the complexity of the patient's case, I should not have to spend more time coding the chronic conditions than I do the reason for the patient visit. I work for a community-based oncology group and some chronic conditions have a direct impact on patient care while others have no impact at all. We are currently planning a physician education meeting for the near future so I hope we get some other thoughts on this topic.