What Diagnoses are not appropriate in a Physician Office Setting?

There are a number of diagnoses not likely to be treated in a doctor’s office.  Often, these are documented in the medical record and submitted to us.  These conditions are things like CVA (stroke), Acute Respiratory Failure, Sepsis, and Acute coronary syndrome and Acute MI that are normally treated in a hospital setting.

In almost all cases, these conditions are submitted based on a misunderstanding of ICD-9 rules.   Usually, the physician documents something like  “CVA” in the medical record, and then chooses the diagnosis code for CVA for submission to the health plan. 

The problem is that most patients who are having a stroke are not seen in a doctor’s office. It’s true that on rare occasions, the patient does appear in a doctor’s office with a life threatening condition, but usually the physician is trying to convey that this is a problem that occurred in the past.

Physicians generally document as a way of capturing what’s wrong with the patient.  But there is another reason—it can serve as a reminder for the physician what they thought about at the last visit.  So, if they see “CVA” or “acute respiratory failure” listed on the last note, they know that this is a patient who had a CVA or acute respiratory failure in the past.  

Acute MI is a little different, and coding for Acute MI is appropriate for 8 weeks after the event.  Because there’s a lot of confusion about acute MI coding, we’ll be doing a separate blog posting on this in the future.

Physicians need to be educated that there are codes for the history of many illnesses, most of them are in the “V” section of the ICD-9.  History of MI is an exception—it’s ICD-9 412.  History of something like pneumonia or septicemia can be coded to V12.09 (personal history of other infectious disease) if the physician documents the history of and considers it a significant diagnosis.

Documentation of these historical conditions should make it clear that it is a disease that occurred in the past. Any condition that is no longer being treated should be noted to be a history of the condition.  Where a code for the history of the disease exists, it should be submitted using that code, not a code for the acute condition.

Coders need to be aware that even when a physician documents one of these conditions, they should not code them. It’s important to educate the physician and explain that these acute conditions should be documented and submitted as a “history of” code.

Do you have a have a confusing coding issue that you're dealing with? Drop us a line at coding@scanhealthplan.com, or leave us a comment and we'll do what we can to help!