How to bill for multiple chronic conditions

March 10, 2012

Questions include code numbers for multiple chronic conditions and how to ensure accurate claims. Find out the answers to pressing coding questions.

Q: If a patient has multiple chronic conditions, are we expected to include the code number for each condition when billing for a visit?

The term chronic usually is applied when the course of a disease lasts more than 3 months. A chronic disease generally is of long duration and slow progression, whereas an acute disease has an abrupt or rapid onset. Because chronic diseases are treated on an ongoing basis, they 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 visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. Conversely, do not report conditions that do not require or affect patient care, treatment, or management.

Use the ICD-9-CM codes that describe the patient's diagnosis, symptom, complaint, condition, or problem.

Assign codes to the highest level of specificity. Use the fourth and fifth digits when ICD-9-CM deems necessary.

Do not code suspected diagnoses in the outpatient setting. Code only the diagnosis symptom, complaint, condition, or problem reported. Medical records, not claim forms, should reflect that services were provided for "rule out" purposes.

Code a chronic condition as often as applicable to the patient's treatment.

Chronic conditions that have an effect on a physician's medical decision-making may not be the reason the condition is treated or investigated during the visit. The main reason for the visit, or what was addressed during the visit, should be the first diagnosis listed on the CMS-1500 form. This is called the "first-listed diagnosis" and should agree with the sequence listed in the assessment of the patient's medical record.

It is important to consider that, as you treat the chronic condition consistently, the cost of care per diagnosis will become an outlier. By this, one means that physicians may tend to list the diagnoses in terms of severity of illness to justify medically a higher level of service, not the acute condition that was treated.

For example, three physicians use the diagnosis 250.00, Type II Diabetes Mellitus, controlled, as the primary diagnosis for a patient's visit. Dr. A's data collected by third-party payers found within a 6-month period that costs for this diagnosis are $650. Dr. B uses the same diagnosis and has claims totaling $1,125 for the same period, and Dr. C's claims total $1,525. The average third-party payer expenditure is $1,200.

Dr. C is an outlier, and the care he is providing can be challenged. It might be that the patient seeking care from Dr. C was treated for another condition, which was the reason for the visit, although the claims listed the diabetes as the reason for the visit.

Some special cases exist that should be mentioned in connection with diagnosis coding. Consider the medical necessity of an encounter in the emergency department, because claims for an encounter with a chronic condition diagnosis are likely to be denied.

For example, consider a patient with a history of asthma presents with severe wheezing, coughing, shortness of breath, and chest tightness. By coding the exacerbation of the chronic condition (severe wheezing, etc.) as the first-listed diagnosis, which is the reason for the encounter, and the chronic asthma as the secondary diagnosis, the claim is likely to be reimbursed.

The place of service should not dictate the diagnostic code, only the documentation.

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