A diagnosis code may only be reported if it is explicitly spelled out in the medical record. Be sure diagnosis code(s) billed are consistent with medical record documentation. Report diagnosis codes as specifically and accurately as possible.
Lack of specificity is an issue, such as unspecified arrhythmia versus a specific type of arrhythmia.
Documentation must show that condition was monitored, evaluated, assessed, or treated (MEAT). Treatment is prima facia evidence of a diagnosis—if you’re treating, it therefore exists.
Cancer status is unclear and treatment is not documented.
Electronic health record must be authenticated and electronically signed with a legible signature with credentials.
Diagnosis and procedure codes billed should accurately reflect the level of service supported by the patient’s medical records.
A discrepancy exists between billed diagnosis and actual description of the condition noted in documentation.
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).
Chronic conditions and status codes are not documented on an annual basis. Chronic conditions such as hepatitis are not documented as chronic.
Code all documented conditions, which coexist at the time of the visit that require or affect patient care or treatment.
Required linking language, causal relationship, or manifestation codes are missing.
The three diabetic HCCs are part of a hierarchy, where HCC 17 is ranked highest and HCC 19 is ranked lowest.
For risk score calculation, only diagnoses within the highest ranked HCC within a hierarchy are captured for a patient encounter.
Not all HCCs are part of a hierarchy, which makes documenting diabetic diagnoses to the greatest specificity so important.
HCC 17
Diabetes with Acute Complications
Diagnoses included in HCC 17 are diabetic ketoacidosis, hypoglycemia or hyperosmolarity, with or without coma.
Patients with acute, life threatening complications such as these often use the greatest amount of health care resources.
HCC 18
Diabetes with Chronic Complications
Diagnoses included are diabetes without complications and the diagnosis long term use of insulin.
Five of the six diagnoses have “without complications” in their narrative description.
HCC 19 has the greatest opportunity for clinical documentation specialists in reviewing documentation,
looking for clinical indicators, lab values and abnormalities in the physical exam to generate a compliant query for diabetes specificity.
HCC 19
Diabetes without Complication
Chronic diabetic complications of neuropathy, retinopathy and chronic kidney disease to list a few.
Patients with diabetes are susceptible to chronic conditions that affect renal, nervous and cardiovascular systems.
Many patients have several diabetic complications concurrently.
Documenting and coding the progression of diabetes and the associated complications is so important in today’s quality and risk adjustment world.
What type is it?
Diabetes mellitus due to underlying condition
E08.-
Drug or induced diabetes mellitus
E09.-
Type I diabetes mellitus
E10.-
Type II diabetes mellitus
E11.-
Other specified diabetes mellitus
E13.-
Commonly Used Type 2 Diabetic Complication Code Combinations?
Document the activity of Deep Vein Thrombosis (if known):
Acute DVT of lower extremities – I82.409, I82.419, I82.429, I82.439, I82.449, I82.499, I82.4Y9 (use caution when assigning these codes as this does not usually occur in the physician office setting)
Classify depression by episode (single or recurrent), the severity (mild, moderate, severe with and without psychotic features) and the clinical status of the current episode:
Episode
Severity
Description
ICD-10-CM
Single
Mild
Major Depressive Disorder (mild)
F32.0
Recurrent
Mild
Major Depressive Disorder (mild)
F33.0
Single
Moderate
Major Depressive Disorder (moderate)
F32.1
Recurrent
Moderate
Major Depressive Disorder (moderate)
F33.1
Single
Severe without psychotic features
Major Depressive Disorder (severe)
F32.2
Recurrent
Severe without psychotic features
Major Depressive Disorder (severe)
F33.2
Single
Severe with psychotic features
Major Depressive Disorder (severe with psychotic features)
F32.3
Recurrent
Severe with psychotic features
Major Depressive Disorder (severe with psychotic features)
F33.3
Recurrent
In remission, unspecified
Major Depressive Disorder (in remission, unspecified)