With the increasing requirements to use all the appropriate codes applicable to a given patient encounter in ICD-10, there may be many more diagnosis codes present for any given visit than we have been accustomed to seeing with ICD-9. Many EHR coding engines use the number of codes to determine the number of diagnoses/problems as a part of calculating medical decision-making levels and the final E&M codes for the visit. Is it appropriate to take credit for these “additional” diagnoses, or should the E&M code be reduced to match pre-ICD-10 levels for the visit?
The implementation of ICD-10 has all of us reevaluating diagnosis coding. While ICD-10 is more specific in many areas, some of the concepts that are being addressed in training are actually pointing out the failures we have made with ICD-9 and attempting to have us make the necessary changes to code correctly as we transition to ICD-10. With quality and other potential factors being evaluated for reimbursement, the inclusion of comorbidities, more accurate diagnoses, and qualifiers will become a differentiating factor in payment. The sooner you get on board, the better your data will be.
With that caveat relative to quality data, you will need to be careful with how this affects your coding. Generally, the documentation guidelines list problems/diagnoses as a part of medical decision making. Our general focus and that of most auditors revolves around the active problem(s) being addressed and the corresponding diagnoses. Comorbidities are specifically listed for consideration under the table of risk for both presenting problem and as a risk to the patient due to the diagnostic test or treatment selected.
In short, for number of problems/diagnoses, you should only count a problem (new or established) that is being diagnosed or treated once, regardless of the number of diagnoses that are listed.
We have cautioned many times about relying on the E&M code calculator to determine the level of E&M code you should charge. The calculator may be suggesting the incorrect code for many different reasons. Certainly, if your calculator increases the level of medical decision making based on the number of diagnosis codes, then the level of code suggested will be incorrect. The problem(s) being addressed should be used in determining the level of medical decision making, not the number of diagnosis codes reported.
The more specific ICD-10 codes allow for changes to diagnoses as the patient progresses through a workup. Should these be considered new diagnoses for the purposes of billing the encounter? For example, a patient with asymptomatic microscopic hematuria (R31.2) may be found to have benign essential microscopic hematuria (R31.1) once his or her workup is completed. Is that a new diagnosis (and therefore counts more toward medical decision-making complexity) at the time of that later encounter, once the benign nature of the hematuria has been confirmed?
No. As mentioned in the first answer above, the problem is the determining factor in medical decision making, not the diagnosis. The problem with hematuria as mentioned above is a good example in which the diagnosis code may change but the problem did not. Therefore, it would still be an established problem that is being dealt with during the second encounter.
