A patient presents as an outpatient for hernia repair surgery. The provider notes “Crohn’s disease,” in the past medical history and indicates the patient is taking an immune modulating drug for the condition. Per the Official Guidelines for Coding and Reporting, section IV.I: 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). Additionally, section IV.J states: Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Although the patient did not receive treatment during the current encounter, is it appropriate to report the Crohn’s disease as an additional diagnosis?
In the outpatient setting, 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). Based on the documentation submitted, the provider has specifically stated that the patient is receiving treatment for the Crohn’s disease. Although the patient is not receiving treatment during the current encounter, the patient is receiving interval treatment; therefore, Crohn’s disease should be coded and reported. The ongoing treatment does not need to occur during this encounter. The fact that the patient is undergoing treatment for Crohn’s disease affects patient care and management.