Chronics in the clinic
In the clinic setting, you would code chronics that were addressed that day as some part of the reason they were in. If they have a chronic condition, such as diabetes, and they are on meds for it, AND that comes into play with the reason they are in, then it can be coded IF it is documented that way. I wouldn't code the diabetes, for example, if they were in for sinusitis and they just listed their diabetes med in the med list with no other reference of it anywhere else in that visit's documentation. But if they said their illness was affecting their diabetes and they took into consideration their diabetes med or blood sugars when prescribing a med for the illness, then I would. They would need to document that chronic illness in their assessment and/or plan.
I'm not sure how it works in the outpatient world, but if the patient is coming in for a colonoscopy and they assess the chronic conditions and note they are stable on the current meds, I would think then they would be coded.
Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I
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