To Code or Not To Code

By Elena Miller, MPH, RHIA, CCS

The Centers for Medicare and Medicaid Services’ Risk Adjustment model is not new. However, Hierarchical Condition Categories (HCCs) seem to be this year’s buzz word. Vendors are offering training courses to educate on HCCs, specialized risk adjustment coding credentials have been created, and lots of conversations are taking place about chronic conditions and how they impact reimbursement. There’s just one thing that isn’t being said enough: just because it’s documented doesn’t mean that it should be coded. There are coding guidelines that must be applied.

Historically, there hasn’t been a lot of pressure on outpatient or physician coders as it relates to secondary diagnosis code assignment. That is no longer the case. I’ve heard HCCs described as the outpatient equivalent to MCCs and CCs. Now more than ever, outpatient and physician coders are being questioned about accurately applying the secondary diagnosis codes.

There is good news. The coding guidelines related to secondary diagnosis code assignment are very clear and have been constant over the years. Outpatient code assignment should be based on Section I of the coding guidelines which is applicable to all healthcare settings and Section IV which is specific to outpatient services (including provider-based office visits).

Section IV of the coding guidelines has two components that help to direct decisions regarding secondary diagnosis code assignment.

• Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)
• 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. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

1. Does the condition currently exist? Some physicians include resolved conditions in their documentation. For example, a patient is being seen in the emergency department for chest pain. The physician may note that the patient completed treatment for a UTI three weeks ago. The patient’s symptoms have resolved and the physician is not evaluating the condition. This is a notation of a resolved condition; it should not be assigned as an additional code.
2. Is this a current condition, that is being treated or affecting the patient care/management? Same patient as the scenario above. This time, the physician notes that the patient completed antibiotics for a UTI but is still experiencing dysuria. The physician orders a urinalysis and gives the patient another prescription of antibiotics for treatment of the UTI. In this case, the condition is documented as current and is being actively treated. An additional code should be assigned.
3. Is this a chronic condition, in which the patient receives ongoing treatment/care? The patient presents for a well-visit; the physician evaluates the patient for ongoing issues with hypertension and diabetes. According to the American Hospital Association’s Coding Clinic from the third quarter of 2007, chronic conditions such as, but not limited to, hypertension, Parkinson's disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation. In this scenario, hypertension and diabetes should be assigned as secondary diagnoses.
4. Does this history or status have an impact on current care? Facilities may have internal policies in place regarding history/status codes that should be followed. Generally, these codes should only be assigned if they are pertinent to the case.

Elena Miller is the director of coding audit and education at a healthcare system.