Focusing on the Diagnosis Instead of the Problems Addressed Can Impact E/M Scores

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Apr 4th, 2023

How many times have you looked at the diagnosis written in the assessment or impression section of an encounter and knowing it is a bilateral code, wondered if the bilateral condition means you give credit for two problems or just one? What about an acute on chronic condition or combination code that contains two or more diagnoses? 

What is the Difference Between a Diagnosis and a Problem Addressed

While a diagnosis is the identification of the nature of an illness after examination of the symptoms, a problem can be just the signs or symptoms, findings, concern, disease, or a combination of these. The key issue here is that with diagnostic coding, we are matching the problems with a diagnosis code description for reporting purposes, but with Evaluation and Management (E/M) scoring, we are identifying any patient problem that the provider evaluated or treated (addressed) during the encounter and assigning a level of complexity associated with the problem at the time of the encounter.

Assigning Diagnosis Codes

Multiple problems can correlate with a single diagnosis code for reporting purposes. For example, the following singular diagnosis code includes five different problems:

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

Breaking this code description down further, you can see that a provider’s documentation during a single encounter may be related to just one problem or all of the following:

• Hypertension
• Heart disease
• Chronic kidney disease
• Heart failure
• End stage renal disease

Providers may address the singular problem, multiples of them, or all of them during the same encounter, but a full review of the documentation is required to know for certain, not just a look at the assigned diagnosis. The ICD-10-CM coding guidelines instruct coders how to report these related issues, but if the provider is focusing on just the end stage renal disease during this encounter, and all the documentation pertains only to that specific problem, then scoring the encounter should be reflective of that documentation.

Another example might be scoring an acute or chronic condition. A patient who presents with chronic cholecystitis presents with symptoms indicative of an acute cholecystitis and analysis and treatment is focused on the acute condition and the documentation then turns to reducing acute attacks by managing the patient’s chronic condition by way of diet, supplements or medications, and even consideration of a cholecystectomy. In this situation, where the provider is addressing both problems individually, each problem would be scored according to the complexity, not just the acute problem. 

Diagnoses that Include Severity in the Name Can Be Confusing

Some diagnostic code descriptions contain a level of severity within the description itself. For these types of diagnoses, documented in the assessment and plan and assigned a code for reporting purposes, the coder should be able to differentiate between the severity of the disease itself or the severity of the problem at the time of the encounter. For example: 

J45.51 Severe persistent asthma (with acute exacerbation)

There are several types of asthma, one is an intermittent (acute) condition while the other is a persistent (chronic condition). The chronic condition then has levels of severity that relate to the disease, not the status of the problem at the time of the encounter. The National Institutes of Health (NIH) define severe persistent asthma, as

“Severe asthma is present, by definition, when adequate control of asthma cannot be achieved by high-dose treatment with inhaled corticosteroids and additional controllers (long-acting inhaled beta 2 agonists, montelukast, and/or theophylline) or by oral corticosteroid treatment (for at least six months per year), or is lost when the treatment is reduced.”

Looking closer at the diagnostic code description, it shows the patient has an acute exacerbation. However, consider the following scenarios before scoring “chronic condition with severe exacerbation” as the E/M MDM Problems Addressed score for this encounter: 

Scenario 1: The patient’s documentation notes “severe persistent asthma with an acute exacerbation, now doing well on the new medication. Looking in the subjective portion of the encounter notes we also see the patient was hospitalized last week for a severe exacerbation of this condition, underwent medication changes and is presenting for follow-up and further management. 

Scenario 2: The patient presents in the ED for “severe persistent asthma with acute exacerbation” currently unable to get it under control even with the rescue inhaler. Difficulty breathing and chest tightness is concerning. The ED provider attempts to bring the condition under control but it flares again. The decision to admit the patient was made in hopes that in a couple of days they will be able to not only control the asthma attacks, but change the patient’s medication regimen to prevent future exacerbations like this one. 

Scenario 3: Hospital day 3: The patient is a 2-year-old who was admitted for severe exacerbation of her severe persistent asthma. The asthma is now under control, the patient is stable, the family has new medications and been instructed on their use, and they will follow up with their asthma doctor this week.

As you can see, the diagnosis never changed between these patient scenarios; however, the circumstances or complexity of the problem, at the time of the encounter, did change. For the purposes of scoring the complexity of the problem(s) addressed during an E/M encounter, we must pay attention to the documentation that describes the complexity of the problem and not just the diagnosis description. For additional scenarios and explanations, sign up to attend the FREE upcoming webinar through Find-A-Code. 

Click HERE to register for this FREE webinar, "Diagnosis vs Problem EM MDM" scheduled for Thursday, April 6, 2023 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET.

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.