Cracking the Code

Reporting an Additional Diagnosis with a Combination Diagnosis Code

It can be confusing for medical coders to know when it is appropriate to report an additional diagnosis when a combination diagnosis code is already reported. When reporting a combination diagnosis code, instructions in the tabular index may state “use additional code to identify specific condition”. The keyword in this guidance is SPECIFIC. If the documentation does not provide specificity, then the additional diagnosis is NOT appropriate for reporting along with the combination diagnosis code.

Anemia was specified, so the additional diagnosis is reported. Obesity was not specified, so only the pregnancy diagnosis for obesity is reported.

Reference: References: AHA Coding Clinic Third Quarter 2018, page 4 and First Quarter 2017, page 25
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