One of the challenging areas of clinical coding is when and when not to code a “Chronic Condition,” whether for inpatient or outpatient coding. Certainly, we’ve all heard about the increased frequency in chronic conditions in our population, especially elders, and more and more data collection and analysis has been and continues to be conducted. For the coding professional, having a clear understanding of chronic conditions and how to interpret and apply the Official Guidelines for Coding and Reporting is a great place to start and refresh your knowledge.
Chronic conditions are those conditions which are defined by the Centers for Disease Control and Prevention (CDC) as a condition that last 12 months or longer and meets 1 or both of the following tests: 1) it places limitations on self-care, independent living, and social interactions; and 2) it results in the need for ongoing intervention with medical products, services, and special equipment.
The CDC has stated that six in ten Americans live with at least one chronic disease, like heart disease and stroke, cancer, or diabetes. These and other chronic diseases are the leading causes of death and disability in America, and they are also a leading driver of health care costs. Other chronic conditions mentioned by the CDC are, “Alzheimer’s disease, Chronic Lung Disease and Chronic Kidney Disease.
We also often see the language of “chronic systemic condition”, typically meaning…the systemic condition affects more than one body system and/or not a single body part. When an individual has multiple chronic conditions, there is a noticeable negative impact or effect on activities of daily living, economics, healthcare management, treatment, costs and longevity. Documenting and capturing these chronic conditions is vital to the true patient story and outcomes.
The Official Guidelines for Coding and Reporting for ICD-10-CM provide great insight into chronic condition coding, within Section I, page 8 of the Conventions:
( ) Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. The nonessential modifiers in the Alphabetic Index to Diseases apply to subterms following a main term except when a nonessential modifier and a subentry are mutually exclusive, the subentry takes precedence. For example, in the ICD-10-CM Alphabetic Index under the main term Enteritis, “acute” is a nonessential modifier and “chronic” is a subentry. In this case, the nonessential modifier “acute” does not apply to the subentry “chronic”
Also listed under the conventions, is the following guideline to remember:
- Default codes
- A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.
Under the “General Guideline” section of the Official Guidelines for Coding and Reporting there is a specific guidance for “Acute and Chronic Condition”.
“If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.”
This is an extremely helpful guideline for proper sequencing and this applies to both outpatient and inpatient coding as it is contained within the General Guidelines which applies to all healthcare settings. When conducting a data analysis, the reviewer should look for both acute and chronic diagnosis codes for the same condition to be assigned and then validate the proper sequencing.
The Official Guidelines for Coding and Reporting of ICD-10-CM also clearly states that Uniform Hospital Discharge Data Set or UHDDS for reporting an additional diagnosis should be followed. For the hospital inpatient setting we live by the following in coding and reporting of an additional diagnosis or commonly referred to as “secondary diagnosis.” With the following, any one of these would result in a secondary diagnosis being assigned:
- Clinical evaluation; or
- Therapeutic treatment; or
- Diagnostic procedures; or
- Extended the length of hospital stay; or
- Increased nursing care and/or monitoring.
Outpatient: The OGC for the Outpatient setting, has addressed the coding of Chronic Diseases with the following:
- Chronic diseases
- 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).
- 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).
- Patients receiving diagnostic services only
- For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
The American Hospital Association (AHA) Coding Clinic for ICD-10-CM has provided some additional guidance which is extremely helpful in third quarter 2007. Certain chronic conditions which are chronic systemic are always coded when documented only in the history portion of the record unless there if conflicting information. These conditions include the following, but are NOT limited to:
- Diabetes
- Hypertension
- Parkinson’s Disease
- COPD
The above guidance can create some issues with payer denials; when coding chronic systemic conditions like Cystic Fibrosis, Lupus, or Multiple Sclerosis are listed in the health record, but in the absence of documented intervention or further evaluation. However, they are other chronic systemic conditions and they should also be coded when following the AHA Coding Clinic guidance above. Now having said that, it is important to remember that there are some other specific requirements from a federal program, such as Medicare Advantage for risk adjustment, which you also need to take into consideration and apply in order to be compliant.
It is helpful for coding departments, coding companies, etc. to put in place a written policy regarding the coding and reporting of “Chronic” conditions and include systemic also.
I think we all can agree that providers can do a better job of documenting chronic conditions and include any impact on the current care being provided. We can provide awareness and education to clinicians on a regular basis which can help improve or achieve specificity. Coding professionals should closely read the diagnostic information in the health record, interpret it and apply the appropriate ICD-10-CM code(s) for chronic conditions when indicated by the clinical documentation and indicated by the guidelines.
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