Thomas Posted Thu 08th of August, 2013 14:23:17 PM
EX: Patient comes in for a follow up visit. They are obese and have Hypertension. Our primary reason for seeing them is Obstructive sleep apnea. Obesity and Hypertension could be a cause for the Obstructive sleep apnea. We are not treating the obesity or hypertension. Dr. indicates in his notes patient has those 2 diagnosis, but again we are not treating them. Dr. writes the Obesity and Hypertension as a diagnosis to bill. Do I bill those diagnosis along with the Obstructive sleep apnea or not becasue we are not treating it?
SuperCoder Answered Thu 08th of August, 2013 20:15:40 PM
Based on the information given, it sounds as if the doctor has noted the obesity and HTN could be related, and he takes those factors into consideration in treating the patient’s obstructive sleep apnea. So even though he isn’t treating them, they can be reported as additional, coexisting diagnoses (after the apnea) as they affect patient care.
From the ICD-9 official guidelines (http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf):
ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit: List first the ICD-9-CM 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. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.
Code all documented conditions that coexist: Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.