when reporting additional diagnosis, a coder should report diagnosis that affect patient care

Secondary diagnosis: In the CMS Official Guidelines for Coding and Reporting (OCG), “Other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring 1 or more of the following: Evaluation Treatment Diagnostic procedure Increased nursing care or monitoring Extended length of stay

Full Answer

What are the ICD 10 cm official guidelines for coding and reporting?

ICD-10-CM Official Guidelines for Coding and Reporting FY 2020 Pages 112-116: The guidelines for coding outpatient records are very clear in the OCG. These guidelines are provided for use by hospitals/providers and provider-based office visits. Reporting of secondary and/or chronic conditions are often not reported for outpatient encounters.

What is an other diagnosis for reporting purposes?

For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: 1 clinical evaluation; or 2 therapeutic treatment; or 3 diagnostic procedures; or 4 extended length of hospital stay; or 5 increased nursing care and/or monitoring.

Why should I report all secondary diagnosis history and status codes?

Another reason to report all secondary diagnosis, history and status codes is to confirm medical necessity. Some payors will deny tests done outpatient if the medical necessity is not met. Many times medical necessity is determined by the ICD-10-CM codes reported on the outpatient claim.

How to code a diagnosis recorded as “suspected?

How to code a diagnosis recorded as "suspected" in both and inpatient and an outpatient record. Inpatient "suspected" coded the diagnosis as if it existed.

Is interpreted to refer to additional conditions that affect patient care?

"For reporting purposes the definition for 'other diagnoses' is interpreted as additional conditions that affect patient care in terms of requiring:clinical evaluation; or.therapeutic treatment; or.diagnostic procedures; or.extended length of hospital stay; or.increased nursing care and/or monitoring.

Do you code secondary diagnosis?

Identifying and Reporting Secondary Diagnoses It is up to the coder to identify the secondary or additional diagnoses. ICD-10 guidelines state that the entire medical record should be thoroughly reviewed to determine the specific reason for the encounter and the conditions treated.

What additional diagnosis code is reported to show that the patient decided not to proceed?

Z53. 20 - Procedure and treatment not carried out because of patient's decision for unspecified reasons | ICD-10-CM.

What is additional diagnosis?

The secondary diagnosis refers to a coexisting condition that might exist at the time of patient admission. This condition might evolve over the course of the patient's stay, or it might be cause for further treatment.

What does the instruction use additional code tell the coder?

What does the instruction "use additional code" tell the coder? The code selected must be listed second.

When coding a diagnosis What comes first?

Coding conventions require the condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a “code first” note with the manifestation code and a “use additional code” note with the etiology code in ICD-10.

What is code Z71 85 used for?

ICD-10 code Z71. 85 for Encounter for immunization safety counseling is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .

When should Z79 899 be used?

For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence use diagnosis code Z79. 891, suspected of abusing other illicit drugs, use diagnosis code Z79. 899.

How is the order of secondary diagnosis codes determined?

1. The first rule of sequencing multiple secondary diagnosis codes is to follow instruction notes (you'll see those in red letters) at the Tabular Index. They will read like this: code first ... which will alert the coder to add that code BEFORE the one he/she is verifying at the Tabular Index.

Can you have two primary diagnoses?

There still can be only one principal diagnosis. The first thing I do when I review a record of a patient admitted with multiple diagnoses, which could potentially meet the principal diagnosis definition, is separate out the conditions and evaluate each one individually.

Where are the Official Guidelines for Coding and Reporting published?

the NCHSGuidance for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). This guidance is to be used as a companion document to the official version of the ICD-10-CM as published on the NCHS website.

How do you determine the principal diagnosis?

Principal diagnosis describes the underlying cause behind a patient's initial hospital admission and is assigned only after a physician has completed necessary tests and examinations.

What is the final impression by the physician?

The final impression by the physician is COPD exacerbation. In this case, a code for the COPD exacerbation would be reported as well as “Z” codes for personal history of pneumonia, history of smoking, and family history of lung cancer and colon cancer.

What happens if secondary diagnoses are not reported?

If secondary diagnoses are not reported, then HCC’s are not captured for the claim. This may impact reimbursement and quality measure statistics. Below are several websites that are available and that go into great detail about what HCC’s are, how they are calculated, and why they are important.

Why do you report secondary diagnosis?

Another reason to report all secondary diagnosis, history and status codes is to confirm medical necessity. Some payors will deny tests done outpatient if the medical necessity is not met. Many times medical necessity is determined by the ICD-10-CM codes reported on the outpatient claim. For example, if an EKG is done on a patient in an encounter for outpatient fracture repair, and the chronic atrial fibrillation is not coded as a secondary diagnosis by the coder, the EKG charge/reimbursement could be denied by the payor. There are also many other examples, such as a patient getting extended laboratory tests because they are on long term anticoagulants such as Coumadin. It is very important that all secondary diagnosis/status/history codes be reported on the outpatient claim.

Is chest pain a symptom of GERD?

GERD. Since the physician has listed out the symptom of chest pain and has not documented that the chest pain is due to the diagnosis of GERD (in the dictation) both the symptom code of chest pain and the diagnosis of GERD would be reported. The coder should not make the assumption that the chest pain is due to the GERD.

When should chronic conditions be reported?

Chronic conditions should be reported on each visit when they are under treatment or are systemic medical conditions. Chronic systemic conditions should be reported even in the absence of intervention or further evaluation.

Can a code be reported on a radiology report?

Coders may report confirmed diagnoses on radiology and pathology reports (except for incidental findings) “Z” codes help paint the entire health picture for the patient. If there is a specific code for a past or family condition, it will most likely always be reported. Code only confirmed diagnosis on outpatient encounters.

Can't describe HCC?

If you can’t describe what HCC’s are, it is recommended that you review some of the websites above and become familiar with these. If you know the why things are reported it is easier to remember to report them. Coders must review the entire outpatient encounter rather than only focusing on the reason for the visit.