Ask the Expert

This month’s selection:

As a risk adjustment coder for many years, my training has been that in order to capture a hierarchical condition category code, minimal documentation is required. For example, if the assessment and plan states: “Diabetes w/o complications (E11.9), stable, continue meds,” it is sufficient documentation to abstract the code, but recently, I’ve been seeing information that says that this may not be enough documentation and wanted your feedback.

Donna Laughlin, AS, CPC, CRC
ACO Coding Specialist – Physician Practices
Einstein Care Partners (now part of Jefferson Health)

Response:

The Risk Adjustment Data Validation documentation guidelines for additional diagnoses have long referenced the ICD Diagnostic Coding and Reporting Guidelines for outpatient as well as inpatient services to help us differentiate when to report chronic conditions. For example, the following statements from Section IV for outpatients would support coding diabetes in the example that you have outlined:

• Chronic diseases treated on an ongoing basis 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 encounter/visit and that require or affect patient care, treatment, or management.

Diagnoses such as hypertension and diabetes are good examples of coexisting conditions that continually affect patient care. In the example you provided, we believe the documentation supports an E11.9; if there were complications, however, we would expect there to be more robust documentation, and potentially more challenges associated with ensuring MEAT criteria is met.

— Paul Wojnar, CPC, CPCO, CRC, CEMC, is coding compliance officer at Nym Health.