AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 3; Clarification

Reporting of Additional Diagnoses in Outpatient Setting

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. ...

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