One of the hardest parts when reviewing a medical record for coding or auditing is the determination of what conditions were addressed. Any condition that is taking into account or affects patient care, treatment or management should be documented and ultimately coded. However, the documentation still needs to support that the provider did in fact review, consider, or treat a condition in order for it to be supported. And whether it is supported affects more than just what ICD-10 code ends up on the claim. Showing the additional work affects the overall medical necessity of the visit, the level of medical decision making, and ultimately, the level of service that is supported. In addition, as many hospitals and clinics are becoming accountable care organizations, the right diagnosis becomes paramount in receiving appropriate reimbursement for the care of the patient.

Making the right diagnosis selection relies on using proper documentation that supports the most accurate representation of the condition. Many coders and healthcare workers will be quick to mention the giant gap in what is clinically significant and how it translates into coding. To assist in closing the gap, consider the following points.

When choosing your diagnosis code:

• The condition must be clearly documented in your assessment with a plan of care addressing it.

• Document and code for all problems assessed during the encounter, not just the primary reason for the visit.

• If it is not addressed, it should not be coded. If there is nothing in the history, exam, or plan of care associated with the condition it is not supported as being addressed.

• When a condition impacts the management of an unrelated diagnosis, the impact should be clearly documented.

Resolved problems or past history:

• From a coding perspective, the statement 'history of' means the patient no longer has the problem, and is no longer receiving treatment for that condition.

• If the condition is still receiving active treatment, it should not be documented as 'history of'.

• If a personal history of a resolved condition or a family history of a condition is relevant to the present concerns, then it is documented and coded as 'history of'.

Documenting undiagnosed conditions:

• Code for conditions described as 'probable', 'rule- out', 'consistent with' or any term that indicates any level of uncertainty is not supported for professional services. Instead, the sign or symptom should be coded. Facilities may choose to code for these as it shows the medical necessity of utilizing additional supplies.

• Document to the greatest degree of certainty for each diagnosis.

Diagnoses with cause/effect relationship or manifestations:

• When documentation mentions the conditions but without a stated causal relationship, each condition is coded separately. There is no assumed connection between the presence of a disease and another condition.

• The exception to the causal relationship guideline is for when hypertension and chronic kidney disease are both present, it is assumed to be hypertensive chronic kidney disease which is coded with I12._ versus I10. If the documentation clearly states that the hypertension and chronic kidney disease are not related, then it may be coded separately.

• In order to code a disease or condition as a manifestation of the disease, the causal relationship must be noted. For example: diabetic nephropathy, hypertensive heart disease or retinopathy due to diabetes.

Making the right diagnosis selection with proper documentation will support the more complex level of medical decision making, and will allow the provider to accurately capture the value of the work they performed.