AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 3; Clarification
Reporting of Additional Diagnoses in Outpatient Setting
Coding Clinic, Third Quarter 2020, page 33, advised against assigning a code for the patient’s mental health conditions since the provider did not document that the conditions affected patient care and management. It was also noted the patient was currently on antipsychotic medications for their chronic mental health conditions. This advice seems contradictory to Coding Clinic, Third Quarter 2019, pages 5-6, where a code for Crohn’s disease, a chronic autoimmune disorder, was assigned for a patient on interval immune modulating drugs to treat the condition. Coding Clinic established that ongoing treatment did not need to occur during the encounter; the fact that the patient was undergoing treatment affected patient care and management. It seems as though ongoing treatment with antipsychotic medications constitutes affecting patient care and management. Would the advice in Coding Clinic, Third Quarter 2020, change for conditions that have potential to exacerbate during care, such as autism or schizophrenia? Please provide clarification on the coding of chronic conditions in the outpatient setting. ...
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Article Overview
This article reviews a Coding Clinic discussion about reporting additional diagnoses in the outpatient setting and compares guidance across different quarters of 2019 and 2020. It is relevant to coders, compliance staff, CDI professionals, and HIM teams who work with outpatient diagnosis reporting, chronic conditions, and documentation support. The piece focuses on how the guidance addresses whether certain ongoing treatments and condition-related factors support reporting additional diagnoses, without serving as a coding reference for specific code selection.
Why This Topic Matters
Outpatient diagnosis reporting depends on documentation and the relationship between the condition, treatment, and patient care. This article helps readers understand how Coding Clinic guidance may affect whether an additional diagnosis is supported in the record and why similar scenarios can be interpreted differently over time.
What You Will Learn
- How Coding Clinic guidance addresses additional diagnoses in outpatient records
- How documentation and ongoing treatment relate to reporting considerations
- How differing Coding Clinic examples are compared in the article
- What types of outpatient scenarios are being questioned for guidance consistency
Who Should Read This
- Outpatient coders
- HIM professionals
- CDI specialists
- Compliance teams
- Revenue cycle staff
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