The Coding Cove
- Katharine Barbagallo CPC,CPMA, CRC, CPC-I
- Dec 13, 2017
- 1 min read
Q. In addition to the primary diagnosis, what other diagnosis codes should I assign to a visit?
A. If the patient has a condition that would be affected by the treatment or may complicate the condition you are treating, it should be coded. You want to show the “full burden of care”.
Example: A patient with chronic diarrhea will be scheduled for a colonoscopy, the patient also has persistent atrial fibrillation with long-term anti-coagulant use. The recommended codes would be R19.7 (diarrhea), I48.1 (persistent A-fib) and Z79.01 (long-term anticoagulant use). Section IV,J of the ICD-10 guidelines states, “ Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.”
Q. Why does the order of the diagnosis codes matter?
A. You should always follow the guidelines that have been established for the ICD-10 code set. Section IV, G of the ICD-10 guidelines for outpatient services states: “List first the ICD-10 code for the diagnosis condition, problem or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.”
The reason for the visit would determine the first diagnosis; there may be other guidelines that need to be followed for the remaining codes. Improper sequencing may cause denial of claims.