Coding Tip: Coding Diagnoses on Outpatient Encounters
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
This coding tip is intended to clear up any confusion regarding coding and reporting of secondary diagnoses on outpatient encounters.
What are HCC’s?
One reason that coders should report chronic conditions (including history and status codes) on outpatient records is the HCC’s—Hierarchical Condition Categories. The quick and easy explanation of what HCC’s are is each HCC is mapped to certain ICD-10-CM codes or code ranges. HCC coding is designed to estimate future health care costs for patients. Insurance companies assign the patient a risk adjustment factor (RAF) score. This score is used to predict costs for that patient. The HCC’s help explain the complexity of the patient and paints a whole picture of the patient and their illnesses. 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.
Learn more about Hierarchical Condition Categories (HCC’s) here:
- https://www.aapc.com/risk-adjustment/risk-adjustment.aspx
- https://www.miramedgs.com/blog/cms-hcc-risk-adjustment-auditing-a-necessary-evil.html
- https://www.aafp.org/practice-management/payment/coding/hcc.html
- https://www.aafp.org/fpm/2016/0900/p24.html
- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2015-RiskAdj-FactSheet.pdf
- https://www.healthaffairs.org/do/10.137/hblog20190420.666282/full/
- https://www.3mhisinsideangle.com/blog-post/hcc-coding-whats-the-big-deal/
- https://bok.ahima.org/doc?oid=302516#.XjxVV8hKiUK
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. Omitting and/or failure to report these diagnoses do not paint a complete picture of the patient. Below, we will discuss some of the OCG’s for outpatient reporting.
- Reporting signs and symptoms: Codes for signs and symptoms are acceptable as long as an established diagnosis for the symptom has not been provided. In the absence of facility specific coding guidelines, HIA coders should follow the Symptom Coding for Ancillary, ER and Outpatient Surgery Cases. If the provider does not specifically link a particular sign or symptom to a diagnosis, both the diagnosis and the sign/symptom would be reported. The reason for coding both is that there may be additional workup planned or necessary for the sign/symptom. If the provider does state a link then only the documented condition would be reported. Examples are below:
- Patient presents to the emergency department with chest pain and arm pain. The provider lists in the final impression or final diagnosis 1). Chest pain; 2). 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.
- Same patient as above except the provider states in the dictation that the cause of the chest pain is GERD and the final impression or final diagnosis is 1). GERD. Only a diagnosis code of GERD would be reported. If the provider had listed out the diagnosis of chest pain in the final impression then the coder would also pick up the code for the chest pain.
- Patient presents to the emergency room with abdominal pain in the upper left quadrant and during interview with the provider it is noted that the patient also has pain during urination. The patient is discharged with the final diagnosis of 1). Abdominal pain due to diverticulosis. In this case, diverticulosis would be coded but not the abdominal pain. The symptom of pain during urination would be reported as well since resources were used to evaluate it.
- Reporting codes for encounters for circumstances other than a disease or injury: Codes Z00-Z99 are provided so that codes for past diseases or other histories can be reported for the patient. Family history codes may also be pertinent for outpatient encounters. If a past history or family history has an impact or influences care and/or treatment in any way the history should be reported. HIA does have a document for “Z” codes that should ALWAYS be reported regardless of patient type unless there are specific facility guidelines that advise otherwise. Here are a few examples:
- Patient presents for outpatient visit for difficulty breathing. The patient has COPD and has had pneumonia several times in the past couple of years. The patient does have a history of smoking and a family history of father with lung and colon cancer. 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. All of these histories are pertinent and help to describe the patient’s history and possible future workups needed.
- Patient presents for difficulty urinating and is diagnosed with BPH. In the patient’s record it is noted that there is a family history of ovarian cancer in the mother and prostate cancer in the father. In this case, a code for BPH is reported along with the “Z” code for the past history of prostate cancer. No code would be reported for the family history of ovarian cancer since this is a male patient and no future workup would be needed for this family condition.
- Uncertain diagnoses are NOT reported in the outpatient setting. The signs, symptoms, abnormal test results or other reason for the visit would be reported.
- Chronic diseases in the outpatient setting should be reported. If a condition is under current treatment it should be reported for each visit as long as the patient is receiving treatment for the condition. Remember though that there are chronic diseases that are systemic conditions and the patient will have them for the remainder of their life. Some of these are HTN, COPD, asthma, emphysema and diabetes. It may be that some research is necessary to determine if the condition is one that has a cure or if it is one that they will have forever.
- Patient presents with upper respiratory symptoms for evaluation. During the evaluation it is noted/documented that the patient has a past medical history of HTN. The patient is no longer taking medications for HTN and it is controlled by dieting and recent weight loss. The patient is diagnosed with URI and given antibiotics. Should HTN be coded? YES! There are many over the counter drugs to treat URI symptoms that should not be taken by patients with HTN. The drugs raise blood pressure just by using as directed.
Medical Necessity
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.
Outpatient Coding Tips:
- All outpatient orders should be reviewed to determine if additional signs, symptoms or diagnoses are provided
- 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
- Remember to report any long term use of specific medications
- Sometimes it is the “Z” codes that will help meet medical necessity for outpatient testing
- 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. These conditions will affect patients for the rest of their lives or most of their lives and require continuous clinical monitoring and evaluation. Certain medications are not to be used if a patient has a certain condition or can’t be mixed when taking a certain medication. This should always be part of the physician’s medical decision making process.
- Coders may not assign a diagnosis code based on the up/down arrows on an order or MD note.
- Coders should remember that additional diagnoses reported on claims can help in supporting the medical decision making that went into treating this patient
- Any diagnosis that requires treatment or monitoring would be reported regardless of if it is chronic or develops during the visit
- Past medical conditions and diagnoses help improve the communication to other healthcare providers and registries. The diagnoses are not just reported for payment but statistics.
- Signs and symptoms may be reported in addition to specific diagnosis codes if the physician has not clearly documented the link between signs/symptoms and the condition. This is due to limited documentation in outpatient records and the need for additional follow up testing that may be necessary (see examples above).
- 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. Diagnoses and symptoms may be found in radiology order and impressions, orders for labs, anesthesia evaluations, history of present illness, physical exam by the physician, past medical history, current medications and the final impression. Not all of these will be present for every outpatient encounter, but they should be reviewed if present. Reviewing these areas will ensure that all pertinent secondary diagnosis and status codes are reported.
References
ICD-10-CM Official Guidelines for Coding and Reporting FY 2020
Coding Clinic for ICD-9, Second Quarter 2000 Pages: 20-21
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2019 Pages: 5-7
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2013 Pages: 27-28
Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2012 Pages: 90-98
Coding Clinic for ICD-10-CM/PCS, First Quarter 2017 Pages: 4-7
Coding Clinic for ICD-9-CM, Third Quarter 2007 Pages: 13-14
Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2016 Page: 143
Coding Clinic for ICD-10-CM/PCS, First Quarter 2014 Pages: 11-13, 17-18
Happy Coding!
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Part 5: New 2021 CPT Codes | Modifiers, Category III, Evaluation and Management, etc.
This is Part 5 of a five part series on the new 2021 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
Part 4: New 2021 CPT Codes | Urinary, Nervous, Ocular and Auditory Systems
This is Part 4 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes in the urinary, nervous, ocular and auditory systems. There are 2 new urinary/male reproductive system codes with no revisions or deletions; 3 new female reproductive codes with 2 deletions, 0 new with 4 deleted nervous system codes with 5 revisions; 5 new eye category III codes; and finally a 2 new auditory codes with one deletion.
Part 3: New 2021 CPT Codes | Cardiovascular System
This is Part 3 of a five part series on the new 2021 CPT codes. In this series we will explore the cardiovascular system CPT changes. There are 5 new cardiovascular CPT codes added with 0 deletions and 4 revisions.
Part 2: New 2021 CPT Codes | Musculoskeletal and Respiratory Systems
This is Part 2 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include some examples to help the coder understand the new codes. There are 0 new musculoskeletal CPT codes added with 0 deletions and 2 major revisions along with an extensive update to arthroscopic loose body removal requirements. For the respiratory system, there were 2 new codes, one code deletion and no revisions.
Part 1: New 2021 CPT Codes | Integumentary System
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
2020: Year in Review | Coding Education
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
Coding Tip: New COVID-19 Codes Effective January 1, 2021
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
New Technology Add-On Payments (NTAP) For FY2021 – Part 4
In the previous three parts of this four-part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 3
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2021.
New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 2
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 1
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Coding Tip: Reporting “Flash” Pulmonary Edema
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
Client S: $556 increase/record reviewed
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
Coding Tip: Glasgow Coma Scale Coding OCG Update for FY2021
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
Coding Tip: Cardiac Arrest and Cardiac Shock
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
Client X: Let’s Talk Numbers
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Coding Tip: Endarterectomy During Coronary Artery Bypass
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Coding Tip: Update – Coding COVID-19 When the Test is Negative
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
New ICD-10-PCS Procedure Codes for COVID-19
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
New Rule Helps Medicare ACOs During COVID-19 Pandemic
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Part 5: Reasons for AKI Denials and Prevention | AKI Series
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
Part 4: Is Documentation Present to Report Acute Kidney Injury/Failure? | AKI Series
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
Coding Tip: Z Code Reporting for COVID-19
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
FY2021 Proposed Rule and Code Changes Highlights
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
Part 2: Specificity Coding of Acute Kidney Injury (AKI) and Sequencing | AKI Series
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
Part 1: What is Acute Kidney Injury (AKI)? | AKI Series
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
Coding Tip: Covid-19 Diagnosis Coding Common Scenarios
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Reporting Telehealth Services During the COVID-19 Emergency
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
Coding Tip: What is Single Path Coding?
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.