Cracking the Code
The Importance of Reporting Chronic Conditions
Coders must understand the importance of reporting chronic conditions as secondary diagnoses for medical encounters. Per section III of the coding guidelines, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. Chronic diseases are treated on an ongoing basis. They may be coded and reported as many times as the patient receives treatment and care for the conditions.
If a provider has conditions listed in their documentation that do not have bearing on the current visit, then these conditions should NOT be reported as secondary diagnoses. However, if there are conditions listed and documentation supports the patient taking long-term medication to treat these conditions, then it is appropriate for a coder to report them for that medical encounter.