Blue Choice

South Carolina Healthy Connections

Documentation and Coding

Documentation and Diagnosis Coding Tips (May 2015)

Documenting Specificity for Accurate Diagnosis Coding

  • Document the reason for each visit along with all conditions that coexist at the time of the encounter. Coexisting conditions include chronic conditions that require or affect patient care, such as hypertension, asthma, or diabetes. Chronic conditions that coexist need to be documented and reported, at minimum, once per year.
    • Example 1: A patient presents for a regularly scheduled physical examination. A code from category V70 (general medical examination) should be assigned, along with a diagnosis code for any coexisting condition(s) documented and supported in the medical record.
    • Example 2: A patient presents to an ENT specialist for treatment of chronic sinusitis. The patient also has type II DM with secondary CKD. A code from category 473 (chronic sinusitis) should be assigned, followed by codes 250.4x and 585.x for type II DM with secondary CKD.
  • All diagnosed conditions must be expressly stated. Probable, suspected, questionable, rule out or working diagnoses cannot be reported in an outpatient setting per ICD-9 outpatient coding guidelines IV.I.
  • Document the status of diagnoses, test results, prescription management, recommendations, and conclusions in the final assessment and plan.
  • Documentation should clearly reflect how the reported condition was treated and/or managed. Each diagnosis must contain supporting documentation per ICD-9 outpatient coding guideline IV.J and IV.K
    • IV.J: Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the conditions.
    • IV.K: Code all documented conditions that coexist at the time of the encounter and require or affect patient care treatment or management.
  • Use explanatory words to better describe the medical condition. For example:
    • Acute bronchitis
    • Major depression
    • Stable CKD
    • Uncontrolled DM
  • Document the cause and effect relationship when one condition is caused by another condition, such as:
    • Neuropathy due to diabetes
    • Alcoholic dementia
    • Acute myocarditis caused by influenza
    • Cirrhosis secondary to alcoholism
  • When instructed by ICD-9 guidelines, use additional diagnosis codes to fully describe the conditions.
    • Insomnia due to mental disorder (327.02)
      • Code first mental disorder
    • Other late effects of CVA (438.89)
      • Use additional code to identify the late effect
    • Diabetes with peripheral circulatory disorders (250.7x)
      • Use additional code to identify manifestation

Locating Official Coding Advice

  • The American Hospital Association (AHA) Coding ClinicTM is the CMS approved resource for clarification of ICD-9-CM. Volumes are published quarterly and contain new or updated information on the use of ICD-9-CM, as well as clarification of previously published coding advice.

Patient History vs History (of)

  • Providers may document a condition as history (of) to show that the patient has had the diagnosis for a long period of time. The term history (of) from a coding perspective indicates that the patient had the condition in the past and that condition no longer exists.
    • History of CHF: Incorrect
      • Instead document status as compensated CHF
    • History of COPD: Incorrect
      • Instead document status as stable COPD
  • Use V-codes to report historical status if pertinent to the current visit. For example, with a history of CVA:
    • V12.54: Use when no residual effects from the stroke remain.
    • 438.x: Use when documentation supports remaining deficits, hemiplegia, dysphagia, etc.

Signature and Legibility

  • Make sure all progress notes and medical records are signed by the provider using first name, last name, and credentials for each date of service.
    • John Smith, MD
    • Rick Santos, PA
  • Write legibly so others can read it.
    • Other providers need to have a clear understanding of what the documentation means.
    • Good documentation is good patient care.

Status Codes

  • Status codes indicate that a patient is a carrier of a disease, has the residual of past diseases or conditions, or has another factor influencing health. Check the review of systems, physical exam, and/or history section of the medical record. As with chronic conditions, status conditions need to be documented and reported, at minimum, once per year.
    • Organ transplant (V42.x)
    • Dialysis (V45.xx or V56.x)
    • Ventilator (V46.xx)
    • Artificial opening (current) ostomy (V44.x or V55.x)
    • Amputation (V49.6x and V49.7x)
    • Asymptomatic HIV infection (V08)
    • Old myocardial infarction (412)
    • Long-term (current) insulin use (V58.67)
    • Adult and child body mass index, when clinically relevant (V85.xx)

Locating the Correct Diagnosis Code in the ICD-9 Code Book

  • Use a current ICD-9 code book. Become familiar with the coding conventions and follow all instructions related to specific codes. Be aware of include and exclude instructions, inclusion terms, and use additional code and other code-related instructions in the Official ICD-9-CM Guidelines for Coding and Reporting.
  • Locate the term in the alphabetic index and then verify the code in the tabular list. Reliance on EHR systems and cheat sheets alone can lead to coding errors.