Diagnosis coding do's and don'ts for follow-up visits

Code the conditions that require or affect today's care, under the ICD-10-CM Official Guidelines for Coding and Reporting, and leave the rest of the chart's list off the claim.

Nate Peereboom
Co-founder, JotPsych

Your follow-up note lists four chart diagnoses. You raised the sertraline for depression and decided against a benzodiazepine because of an alcohol use disorder in early remission. The other two never came up. Your claim carries all four.

Three do's for today's claim

• Code each condition that required or affected today's care. Check each chart diagnosis against Section IV.J of the ICD-10-CM Official Guidelines, which says to code conditions that "require or affect patient care, treatment or management." For your follow-up, you'd code the depression you treated and the alcohol use disorder that made you decide against a benzodiazepine.
• Write how each diagnosis shaped today's visit. Each diagnosis on your claim needs a line in today's note: a dose change, a new plan, a drug you decided against. "If it's not addressed in this encounter, it doesn't belong in this encounter," said Kem Tolliver, a coding and documentation consultant.
• Mark a diagnosis resolved once the condition ends. Section IV.J also says not to code "conditions that were previously treated and no longer exist." The same section lets you add a history code, Z80 to Z87, as a secondary code when a past condition or a family history affects today's care.

Three don'ts for today's note and claim

• Don't pull in diagnoses from your last note. Tolliver lists a diagnosis mismatch, a diagnosis code that doesn't match the care you provided, as a downcode trigger to expect from payers. She sees clinicians "pulling in diagnoses from the last visit." Your note template may copy the chart's whole list into every visit. Review your template.
• Don't list a secondary diagnosis before the main diagnosis. Section IV.G says to list first the diagnosis "chiefly responsible for the services provided." Tolliver often sees diagnosis codes "sequenced incorrectly."
• Don't code a "rule out" diagnosis. Section IV.H says not to code a diagnosis documented as "probable," "suspected," or "rule out." Code what you're sure of that day, such as a symptom.

Palmetto GBA, a Medicare contractor, defines cloning as copying "previously recorded information from a prior note into a new note." Palmetto warns that identifying cloned documentation "will lead to denial of services for lack of medical necessity and recoupment of all overpayments made." Recoupment means the payer takes back money it already paid you.

Take your last five notes. Match each diagnosis on the claim to a line in that day's note. Leave the rest in the chart.