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.
Coding professionals should not assign codes based solely on diagnoses noted in the history, problem list and/or a medication list. It is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter.
In the case published in Coding Clinic, Third Quarter 2019, pages 5-6, the provider specifically stated that the patient was receiving treatment for Crohn’s disease. When the provider documents that a patient’s condition or treatment thereof affects care and management for the current encounter, the condition should be reported even if treatment did not occur during the encounter.
In the case published in Coding Clinic, Third Quarter 2020, page 33, codes were not assigned for the mental health conditions, since there was no provider documentation that the mental health conditions or their treatment affected patient care and management for the current encounter. If the medical record is unclear or ambiguous regarding which condition(s) affected patient care and /or management of the patient, query the provider for clarification.