Details matter. Medical Coding needs to be precise, and follow the correct diagnostic sequences, to achieve maximum reimbursement and avoid denials. Changing ICD-10 coding guidelines make coding for the broad spectrum of diagnoses seen in critical access and rural health facilities even more challenging. Consulting with experts can help.
The Top 10 Diagnoses Commonly Seen in Critical Access and Rural Health Facilities, with Corresponding Coding Tips:
1. Heart failure: Diagnosis codes for heart failure should be sequenced with the underlying cause of the heart failure listed first. If heart failure is due to hypertension, the hypertensive heart disease code should be listed before the specific heart failure code. Always follow the “code first” instructions provided in the ICD-10 coding guidelines for accurate sequencing.
2. Pneumonia: Accurate medical coding for pneumonia relies on clinical documentation that specifies the type of pneumonia or its causal agent. Provide sufficient detail, including the causative organism and any underlying conditions, to ensure the most specific coding possible. Also, identify severity of the condition.
3. Acute myocardial infarction: A myocardial infarction (MI) is classified as acute if it occurs within 4 weeks of the initial symptom onset. If more than 4 weeks have passed, it’s considered an old MI. The ICD-10 code for a history of MI, regardless of whether it was initially a STEMI or NSTEMI, is: I25.2 (old myocardial infarction).
4. Diabetes: Code for all types of diabetes a patient may have. For instance, if a patient has both diabetic retinopathy and diabetic nephropathy, code for both conditions. However, you cannot use a specified code and the unspecified E11.9 code together. This would cause a denial because it contradicts the other diabetes codes.
5. Hypertension: ICD-10-CM classifies hypertension by type, as essential or primary (categories I10-I13), and secondary (category I15). Combination codes are used to report hypertension with associated conditions. For example, I11 is used for hypertensive heart disease, and I12 is used for hypertension and chronic kidney disease.
6. Arthritis: Make sure your documentation includes the following key details:
- Type of arthritis (osteoarthritis, rheumatoid arthritis, or other type)
- Laterality (which side of the body is affected), and the specific joints involved
- Prescribed treatments and medications
- Diagnostic findings, including results from imaging or laboratory tests
- Signs and symptoms experienced by the patient
- Objective findings, such as the presence of nodules or other physical manifestations
This level of detail leads to more accurate coding and better patient care.
7. Hepatitis: Chronic hepatitis should be clearly documented as chronic to reflect its ongoing nature. Not specifying the condition as chronic can result in incomplete or inaccurate diagnosis codes.
8. Failing kidneys: Documentation should specify the stage of chronic kidney disease (CKD) and clearly link the condition to underlying causes such as diabetes and hypertension. ICD-10-CM guidelines allow CKD to be assumed as “due to” both hypertension and diabetes, even without explicit linking it, unless the provider attributes CKD to a different condition. Additionally, CKD stage must be included in the code for accurate documentation and reporting.
9. Depression: To code major depressive disorder accurately, documentation should include the following details:
- Symptoms must be present for at least two weeks, whether it is a single or recurrent episode
- Severity must be coded as mild, moderate, severe without psychotic features, or severe with psychotic features.
- Specify if the episode is in partial or full remission.
If documentation lacks this level of specificity, the diagnosis can only support “major depression, unspecified” (F32.9).
10. Substance use: When a patient uses, abuses, or is dependent on the same substance, only one code should be assigned. The ICD-10-CM guidelines for assigning the code state:
- If both use and abuse are documented, assign the code for abuse
- If both abuse and dependence are documented, assign the code for dependence
- If use, abuse, and dependence are all documented, assign the code for dependence
CodeEMR Can Help
Mastering coding specificity comes with experience, focus and ongoing education. CodeEMR, and its parent company, ScribeEMR, are National Rural Health Association Pipeline Partners, with dedicated teams that provide virtual medical coding and audit services, medical scribing, and virtual medical office services to more than 50 rural health facilities nationwide.
Contact CodeEMR today to learn how our services can be customized to meet your specific needs.
