Which Coding System Is Used To Report Diagnosis For Outpatient Services On Claims?

Kim Carrier RHIT, CDIP, CCS, CCS-P
Manager of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

This coding tip is intended to clear upwards whatsoever confusion regarding coding and reporting of secondary diagnoses on outpatient encounters.

What are HCC'southward?

One reason that coders should report chronic weather condition (including history and status codes) on outpatient records is the HCC'southward—Hierarchical Condition Categories. The quick and piece of cake explanation of what HCC'due south are is each HCC is mapped to certain ICD-10-CM codes or lawmaking ranges. HCC coding is designed to estimate time to come 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 assist explicate the complication of the patient and paints a whole picture of the patient and their illnesses. If secondary diagnoses are not reported, and then HCC'south are not captured for the merits. This may impact reimbursement and quality measure statistics. Beneath are several websites that are available and that become into corking detail about what HCC'due south are, how they are calculated, and why they are important.

Learn more about Hierarchical Status Categories (HCC'southward) here:

• https://world wide web.aapc.com/gamble-aligning/adventure-adjustment.aspx
• https://world wide web.miramedgs.com/blog/cms-hcc-risk-adjustment-auditing-a-necessary-evil.html
• https://www.aafp.org/practice-direction/payment/coding/hcc.html
• https://www.aafp.org/fpm/2016/0900/p24.html
• https://world wide web.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2015-RiskAdj-FactSheet.pdf
• https://world wide web.healthaffairs.org/exercise/x.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 articulate in the OCG. These guidelines are provided for use by hospitals/providers and provider-based office visits. Reporting of secondary and/or chronic atmospheric condition are often not reported for outpatient encounters. Omitting and/or failure to report these diagnoses do not pigment 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 adequate equally long as an established diagnosis for the symptom has non 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 land a link then only the documented condition would exist reported.  Examples are below:
  1. 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 non make the supposition that the chest pain is due to the GERD.
  2. Aforementioned patient as higher up except the provider states in the dictation that the cause of the chest pain is GERD and the final impression or final diagnosis is one). GERD. Just a diagnosis code of GERD would be reported. If the provider had listed out the diagnosis of chest hurting in the last impression and so the coder would besides pick upward the code for the chest pain.
  3. 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 last diagnosis of 1). Abdominal pain due to diverticulosis. In this case, diverticulosis would be coded simply not the abdominal pain. The symptom of hurting during urination would be reported equally 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 too be pertinent for outpatient encounters. If a past history or family unit history has an affect or influences care and/or treatment in whatsoever mode the history should be reported. HIA does accept a document for "Z" codes that should E'er be reported regardless of patient type unless there are specific facility guidelines that propose otherwise. Here are a few examples:

1. 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 terminal impression by the physician is COPD exacerbation. In this case, a code for the COPD exacerbation would be reported besides 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 assistance to depict the patient's history and possible future workups needed.
2. Patient presents for difficulty urinating and is diagnosed with BPH. In the patient'south record it is noted that in that location is a family history of ovarian cancer in the mother and prostate cancer in the father. In this case, a lawmaking for BPH is reported along with the "Z" code for the past history of prostate cancer. No lawmaking would exist reported for the family unit 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 handling it should exist reported for each visit as long as the patient is receiving treatment for the condition. Remember though that in that location are chronic diseases that are systemic weather and the patient will accept them for the remainder of their life. Some of these are HTN, COPD, asthma, emphysema and diabetes. It may exist that some research is necessary to determine if the condition is 1 that has a cure or if it is one that they will accept forever.

1. 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 information technology is controlled by dieting and recent weight loss. The patient is diagnosed with URI and given antibiotics. Should HTN be coded? YES! At that place are many over the counter drugs to treat URI symptoms that should not be taken by patients with HTN. The drugs enhance claret 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 washed outpatient if the medical necessity is non met. Many times medical necessity is adamant past the ICD-x-CM codes reported on the outpatient merits. For instance, if an EKG is washed 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 accuse/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/condition/history codes exist reported on the outpatient claim.

Outpatient Coding Tips:

• All outpatient orders should be reviewed to decide 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 by or family condition, it will most probable always be reported
• Code only confirmed diagnosis on outpatient encounters
• Remember to report whatsoever long term use of specific medications
• Sometimes it is the "Z" codes that volition help meet medical necessity for outpatient testing
• Chronic conditions should be reported on each visit when they are under handling or are systemic medical conditions
• Chronic systemic conditions should be reported fifty-fifty in the absence of intervention or further evaluation. These conditions will touch patients for the residue of their lives or most of their lives and require continuous clinical monitoring and evaluation. Certain medications are non to exist used if a patient has a certain condition or can't be mixed when taking a sure medication. This should ever be part of the md'southward medical decision making procedure.
• Coders may not assign a diagnosis lawmaking based on the up/down arrows on an society or MD note.
• Coders should recollect that additional diagnoses reported on claims tin can aid in supporting the medical conclusion making that went into treating this patient
• Any diagnosis that requires treatment or monitoring would exist reported regardless of if information technology is chronic or develops during the visit
• Past medical weather and diagnoses help improve the advice to other healthcare providers and registries. The diagnoses are not only reported for payment but statistics.
• Signs and symptoms may exist reported in add-on to specific diagnosis codes if the dr. has not conspicuously documented the link between signs/symptoms and the status. This is due to express documentation in outpatient records and the demand for boosted follow up testing that may exist necessary (meet examples above).
• If you can't describe what HCC'southward are, it is recommended that you review some of the websites in a higher place and become familiar with these. If y'all know the why things are reported it is easier to remember to written report them.

Coders must review the entire outpatient come across rather than just focusing on the reason for the visit. Diagnoses and symptoms may be constitute in radiology guild and impressions, orders for labs, anesthesia evaluations, history of present illness, physical test by the physician, past medical history, current medications and the last impression. Not all of these will be present for every outpatient encounter, just they should exist reviewed if present. Reviewing these areas will ensure that all pertinent secondary diagnosis and condition codes are reported.

References
ICD-10-CM Official Guidelines for Coding and Reporting FY 2020
Coding  Dispensary for ICD-nine, Second Quarter 2000 Pages: 20-21
Coding  Dispensary for ICD-ten-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: xc-98
Coding  Dispensary for ICD-10-CM/PCS, Start Quarter 2017 Pages: iv-7
Coding  Clinic for ICD-nine-CM, Third Quarter 2007 Pages: 13-xiv
Coding  Dispensary for ICD-10-CM/PCS, 4th Quarter 2016 Page: 143
Coding  Clinic for ICD-10-CM/PCS, First Quarter 2014 Pages: 11-13, 17-eighteen

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 quickly.

Source: https://www.hiacode.com/education/coding-diagnoses-on-outpatient-encounters/

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