Last updated on 1/15/2013
Ask a Coder Frequently Asked Questions
If you have questions about Risk Adjustment, HCC codes, or general coding, please ask our coder at They will be answered in the order received and then posted in our FAQ document.
Q. If I'm coding for my physician seeing hospitalized patients, do I use the Inpatient Coding Guidelines?
A. No. The Inpatient Coding Guidelines are for use by the facility only. Physicians use the Outpatient guidelines, no matter what the place of service is. This is supported by Coding Clinic, 4th Quarter, 2000, which states in part: "When coding for physician services, whether provided in the hospital inpatient setting or in the physician office, coders should be guided by the Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital- Based and Physician Office). The inpatient guidelines are for hospital coding".
Q. What is the diagnosis code for uncontrolled hypertension?
A. The ICD-9 does not categorize hypertension by level of control. Hypertension is categorized as benign or malignant. If a note indicates only "uncontrolled hypertension", the correct coding is 401.9, "hypertension, unspecified". If there is hypertensive heart or kidney disease present, these should be noted and coded in the 402.X or 403.X range. You should not code 401.1 unless your documentation says that the hypertension is benign.
Q. If a patient is on long-term opioid medication for pain, how is this coded? Should we use 304.0?
A. No, the correct code for patients on long term opioid treatment is V58.69 – long term (current) use of other medication. Code 304.0, based on the DSM-IV (Diagnostic and Statistical Manual- 4th revision) is to be used for dependent drug abuse, not the prescribed use of medication, even if the patient has a physical dependence on the drug. Per CMS, clinicians should continue to use the DSM descriptors under HIPAA. See the DSM describes dependence as follows:

DSM-IV definesdependenceas:
  • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
    1. tolerance, as defined by either of the following:
      • a need for markedly increased amounts of the substance to achieve intoxication or desired effect
      • markedly diminished effect with continued use of the same amount of substance
    2. withdrawal, as manifested by either of the following:
      • the characteristic withdrawal syndrome for the substance
      • the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
    3. the substance is often taken in larger amounts or over a longer period than was intended
    4. there is a persistent desire or unsuccessful efforts to cut down or control substance use
    5. a great deal of time is spent in activities to obtain the substance, use the substance, or recover from its effects
    6. important social, occupational or recreational activities are given up or reduced because of substance use
    7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington DC: American Psychiatric Association (APA). 1994.] (For documentation regarding the continued use of DSM Descriptors, please see the Frequently Asked Questions Database on the CMS website at: Search term "DSM-IV")
Q. How do I code a CVA?
A. If the only documentation is "CVA" the default code is 434.91 (CVA –stroke, ischemic). However, if the physician specifies the type of stroke (embolic, hemorrhagic, etc) there are separate codes in the 434.XX section of the ICD-9.

However, these codes are for use during the acute event—i.e., while the patient is still hospitalized. Once the patient has been discharged from the hospital, then coding and documentation should indicate a history of stroke (V12.54). More importantly, sequelae, what ICD-9 calls "late effects" should be documented and coded. Late effects such as hemiplegia/hemiparesis secondary to CVA (438.2X), aphasia (438.11) should be documented and coded. (Coding Clinic, Q4 2004)
Q. If there is a report in the patient's chart and you cannot identify the physician or provider name, is it acceptable to code from this report for risk adjustment?
A. No, you cannot code a diagnosis if you cannot determine who the rendering the provider is. CMS will only accept diagnoses from complete documentation, which must have the diagnosis documented, as well as have the patient's name, date of service, a unique patient identifier (e.g. date of birth or medical record number) and be performed and legibly signed by an acceptable rendering provider (e.g., physician, physician extender, inpatient hospital, or outpatient hospital).
Q. If a patient has type II diabetes, do we need to also code V58.67 if the patient is on insulin? We are coding 250.00 for diabetes, but don't want to upcode or overcode. Is adding V58.67 deemed to be upcoding or overcoding and will we run into compliance issues? Will adding this code lead to an extra risk score?
A. No, it is not upcoding or overcoding for two reasons:
  1. The Coding Clinic calls the use of V58.67 optional ("if desired") (Coding Clinic 2004 Q4)
  2. It doesn't lead to a higher or extra risk score. Both V58.67 and 250.00 or 250.01 group to HCC 19. You don't get paid for HCC 19 twice no matter how many times that you submit the code during the collection period.
There is no reason not to code all applicable diagnoses, since they give CMS a more complete picture of our members. Many diagnoses not in the Risk Adjustment model are part of the RxHCC (Part D) model, so it is important to code all diagnoses, not just diagnoses that lead to an HCC.
Q. If a hospitalist evaluates a patient in the hospital do we follow inpatient or outpatient coding guidelines? Can we submit this data to the health plan?
A. Yes, submit the hospitalist's data to the health plan. Follow the physician/outpatient coding guidelines (Coding Clinic 2000 Q3). All physician services should be submitted to the health plan and the plan submits them to CMS.
Q. A hospice patient had a face-to-face encounter with their PCP and chronic diseases were documented in the medical record. Do we get paid using the Risk Adjustment model for patients enrolled in hospice?
A. No, hospice enrollees are not paid using the Risk Adjustment method.

Please see pgs 23-24 in the CMS Managed Care Manual, which can be downloaded from the from the CMS website, regarding payment for hospice enrollees.

Also, payment lags 1 year behind the service in the risk adjustment model, and you don't receive payment for a patient who expires. The nature of hospice (a physician certifies that the patient has less than 6 months to live) means that most patients won't be alive in the payment year. A patient must be a member in the payment year in order for the group to receive payment.
Q. When reviewing records, if we find "depression" documented three times or more in a twelve-month period, can we assign code 296.30 for major depression, recurrent episode?
A. Under the Official ICD-9 Coding Guidelines, a diagnosis can only be coded when it is explicitly spelled out in the medical record. It cannot be inferred (even when a provider does the coding) that depression documented multiple times in a record is "major recurrent depression." Also, the Diagnostic Coding and Reporting Guidelines for Outpatient Services, pgs 88-91, explain that a diagnosis is often not established during the first visit and it may take subsequent visits to confirm that diagnosis. All diagnoses should be supported by physician documentation.

The physician should clearly document the type of depression in order to assign a more specific diagnosis code such as major depressive disorder. If only depression is documented, code 311 "depression not otherwise specified."

Official ICD-9 Coding Guidelines can be downloaded on the CDC website.
Q. Recently, we received advice that we may amend our medical records to reflect lab data or other new information weeks after the service is rendered. The advice also said that we could then submit corrected diagnosis data for risk adjustment without another face-to-face visit. Is this correct?
A. CMS allows physicians to create an addendum to medical records to reflect confirmation of a diagnosis under certain circumstances. However, the example given by CMS is several days, not weeks, after a visit. Most laboratory and radiology services have results within days, not weeks, and it is expected that addenda will be completed as soon as possible after receipt of the additional information. CMS published this guidance in a training guide that has been removed from the CSSC website, and is no longer available. However, it reads as follows:

6.4.2 Unconfirmed Diagnoses
Physicians and hospital outpatient departments shall not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working." Rather, the condition(s) shall be coded to the highest degree of certainty known for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. CMS recognizes that this is an area where the physician-reported diagnosis and hospital inpatient diagnosis for the same encounter may disagree since hospital inpatient rules allow for coding of suspected conditions as if they were confirmed.

It also is understood that the physician record is not a static document. Positive test results and notation regarding contact with the patient for a revised plan of treatment often are added to the record several days after the patient encounter. When these addenda are made, corrections or additions to the diagnoses submitted to the MA organization may be recommended especially if the HCC assignment is impacted.

Example: 4
A physician removes a mole during an office visit and sends the specimen for pathology. The diagnoses documented are "suspicious skin lesion" (709.9, not in model) and "rule out melanoma." At this point, the diagnosis 709.9 may be submitted, but the diagnosis of melanoma may not. The pathology report is returned several days later and confirms malignant melanoma. The physician reviews the findings, initials the report, and documents in the record the results and notification to the patient. Since the removal of the mole was done during the office visit, the new code (172.9, melanoma) should be submitted with that date of service.

Q. What is the correct code for neuropathy found in a podiatry chart?
A. The ICD-9 indexes the term "neuropathy" to 355.9. The physician's specialty or type of provider does not influence coding, since one can't infer anything when coding. Even though a podiatrist most likely means polyneuropathy, we can't use that knowledge to choose a code. 355.9 is neuropathy NOS and is the correct code if any provider documents "neuropathy."
Q. A PCP had a face-to-face visit with a patient on 11/16/07, but on 12/19/07 he added a note for "chart review" and 2 diagnoses that were previously not documented in the patient's medical record. Would it be acceptable to report these 2 additional diagnoses to CMS? One of the diagnoses added does risk adjust.
A. No, it is not acceptable to report the 2 additional diagnoses from the "chart review." Coding from "chart reviews," "failed visits," or any other progress notes that are not from a face-to-face visit with a patient are not valid sources for risk adjustment coding. This guideline is in the 2008 Risk Adjustment Data Technical Assistance Participant Guide in section 3.2.4.
Q. Can you explain the difference between late effects and after care for fractures? I am in orthopedics and have had two different pieces of advice about fracture care and late effects. Any help you could give would be appreciated.
A. The coding guidelines for late effects and acute fractures vs. aftercare of fractures is below. The Official Coding Guidelines can be downloaded at:

Acute Fractures vs. Aftercare
Traumatic fractures are coded using the acute fracture codes (800-829) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

Fractures are coded using the aftercare codes (subcategories V54.0, V54.1, V54.8, or V54.9) for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase.

Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow up visits following fracture treatment.

Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.

Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate codes.

Pathologic fractures are not coded in the 800-829 range, but instead are assigned to subcategory 733.1X.
Q. What is the correct code for a follow up visit to a physician's office for a patient who has had a myocardial infarction that is less than 8 weeks old? 410.90 or 410.92. Please advise.
There isn't quite enough information to precisely answer the question, but I'll give you enough information so you can determine what the correct 5th digit is. I assume by the way your question is phrased that the physician did not state the area of the heart muscle affected by the MI, which led you to the fourth digit of "9".

Generally, for a patient being seen in the office it won't ever be a fifth digit of 1.

First, the diagnosis code will always be determined by the documentation in the physician record.

The fifth-digit of "0" (unspecified episode of care) means the physician did not provide enough information to determine what episode of care the patient is in.

The fifth-digit of "1" (initial episode of care) covers all care provided to a newly diagnosed myocardial infarction patient until the patient is discharged from medical care (i.e., discharged from the hospital). This includes any transfers to and from other facilities prior to the patient's discharge and occurring within the eight-week time frame.

The fifth-digit of "2" (subsequent episode of care) covers care (further observation, evaluation or treatment) rendered after the initial treatment (discharge), but the myocardial infarction is still less than 8 weeks old.

Once the MI is more than 8 weeks old, the physician should document old MI (ICD-9-CM 412)
Q. What is the correct code for Coronary Artery Disease (CAD)?
A. The correct code for coronary artery disease depends on what information is provided in the documentation. CAD is commonly miscoded as 414.00 (coronary atherosclerosis of unspecified type of vessel, native or graft). However, this is incorrect unless the physician specifically notes that both native and graft vessels are present. Hence, the documentation must include information regarding a previous coronary artery bypass graft (CABG) in order to use this code. When there is no documentation of a prior CABG, then the correct code for CAD is 414.01, coronary atherosclerosis of native coronary artery even though the physician does not state "native artery." This rule was published in Coding Clinic For ICD-9 CM 2nd quarter, 1995 and reiterated in 1st quarter, 2004.
Q. If the patient has both diabetes and peripheral vascular disease, how should this be coded?
A. If the documentation indicates only diabetes and peripheral vascular disease, then the documentation is 250.00 (uncomplicated type II diabetes) and 443.9 Peripheral vascular disease, unspecified. Unless the physician specifically states that the peripheral vascular disease is a complication of the diabetes, or the physician notes "diabetes with peripheral vascular disease" or similar wording, then the two diseases are considered unrelated. This is a change from the longstanding Coding Clinic advice that the physician must state the causal relationship.
Q. How are pathologic (compression) fractures of the vertebrae coded?
A. Pathologic fractures of the vertebrae are coded 733.13.Although the Official Coding Guidelines indicate that the condition should not be coded on an ongoing basis, a recent Coding Clinic (Q3 2008) indicates that if the patient is being treated for a non-healing pathologic fracture, it can be coded as often as treated.
Q. If the patient is a diabetic, and the note indicates that the patient has retinopathy, do you assume it's diabetic retinopathy?
A. ICD-9 does not generally assume a cause and effect relationship between diabetes and other illnesses. Because the physician did not state a causal relationship, through terms like "diabetic retinopathy", or "retinopathy secondary to diabetes", or "diabetes with retinopathy", the correct coding is 362.10, background retinopathy NOS and, if the note indicates that the patient is diabetic, 250.00, DM II, not stated to be uncontrolled. This is a change from the longstanding Coding Clinic advice that the physician must state the causal relationship.
Q. If the patient has both diabetes and peripheral neuropathy, how should this be coded?
A. If the documentation indicates only diabetes and peripheral neuropathy, then the documentation is 250.00 (uncomplicated type II diabetes) and 357.2 diabetic polyneuropathy. Unless the physician specifically states that the polyneuropathy is a complication of the diabetes, or documents "diabetes with polyneuropathy", then the two diseases are considered unrelated. This is a change from the longstanding Coding Clinic advice that the physician must state the causal relationship.
Q. My understanding of CMS' new criteria for signatures is that as of January 1, 2009, CMS will not accept a stamped signature on a progress note. The provider's name must be spelled out with their credentials on each page. Does this do away with the provider signature logs?
A. Signature logs are not the same as a signature stamp. A signature stamp replaces a physical signature. As of 1-1-09, CMS does not accept signature stamps under any circumstances.

CMS has said (on a RADV conference call) that they will not accept signature logs. Although signature logs are acceptable in fee-for-service Medicare, as of this time, CMS will not accept them for Medicare Advantage patients.
Q. If a NP or PA is submitting claims, will they receive a Risk Score? Since they do not have members assigned to them, but to the PCP, will they receive a RA score or does it go to the supervising provider's score?
A. Providers do not have risk scores. Certain of our reports show the risk average risk score of the members assigned to a PCP, or members seen by a given specialty, but these are always a reflection of the members' risk scores.

Most physician extenders are not individually credentialed by health plans. IF they are identified as the rendering provider on incoming encounters (something that doesn't happen consistently) it might be possible to determine the average risk score of members seen by the physician extender. But, it would not be a unique score, since there would always be overlap with the PCP that the members are assigned to.
Q. My query is whether CMS will accept the Diagnosis codes reported from the superbills. In a chart provider has documented the assessment of a patient in the superbill instead of progress notes. For e.g., There is a patient record with the DOS 01/29/09 for which both superbill & progress notes is available. Progress note has Chief Complaint, Vital Signs , ROS & Objective. The assessment was given in the superbill at the bottom.
A. No, CMS specifically says that superbills are not a part of the medical record. See the 2008 Risk Adjustment Data Technical Assistance Participant Guide, page 170. Superbills can only be used to collect data, not as a part of the medical record.
Q. Good morning, If a patient has chronic kidney disease and is hospitalized for acute renal failure, can we (as the provider not facility) code for both conditions 585.9 and 584.9?
A. What a provider can code is always driven by two things:
  • What the provider documented
  • What the ICD-9 coding rules allow
The provider cannot code for any condition he did not document himself, irrespective of what the patient was hospitalized for.

There is no coding rule which says that these are mutually exclusive conditions. If your provider's documentation supports both conditions, then both can be coded.
Q. We have a new member, she is in for her H&P. She was hit by a car last November, suffered multiple traumatic injuries supracondylar femur fracture, fractures of the 9th & 10th ribs with pneumothorax, scalp laceration. How do I code this?
A. It's hard to determine what the patient is being seen for. All of the conditions listed could only be coded as a "history of" IF they were assessed. What should be coded is what the patient was seen and assessed for today. None of these things listed seem to be current conditions.

Risk Adjustment never changes what it is appropriate to code. What we have to be mindful of is what physicians (especially) have often forgotten to code—current conditions that they assess, but don't mark on a superbill; and what physicians have often forgotten to DOCUMENT, so that they can be reminded to do so. For example physicians often have assessed long term chronic problems (like the labs on an A fib patient, or the cardiac status and evaluation for peripheral edema in a CHF patient) but have forgotten to write the diagnosis for these conditions. Education focused on documentation is critical so that physicians are accurately recording what they assess.
Q. Can CAD be related to Diabetes? What would be the codes?
A. From a coding perspective, CAD can be "related to" or caused by or secondary to diabetes only if the physician says so in their documentation. This is why we strongly recommend that physicians be trained in documentation. It doesn't matter if the physician thinks that the diabetes caused the CAD if they don't say so. The coder cannot make that assumption.

If the physician documents CAD secondary to the diabetes, then the correct coding would be 414.01 (see earlier question in "Ask a Coder") and 250.8X – diabetes with other specified manifestations.
Q. Would the code V12.51 be used for history of DVT?
A. Yes. You should also use V58.61 if long term use of anti-coagulants is documented.
Q. Do you continue to report AAA even after it has been surgically repaired?
A. No. Per the coding guidelines, you do not code conditions that no longer exist. From the Official ICD-9 Coding Guidelines:

Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services

K. Code all documented conditions that coexist
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Q. I am hoping I can ask you a coding question regarding diabetes. If a physician bills 250.60 and the manifestation is NOT billed does/can that code stand alone or does it get downcoded to 250.00 by CMS?

Also, if the physician coded 250.60, with no second code selected and manifestation not clearly identified, how can we rebill with the manifestation?
A. In the first scenario, no, CMS doesn't downcode it. It is just processed as submitted. Of course, it must be documented in the medical record appropriately.

In the second scenario, again, CMS does not change the code, but would not allow it in a Risk Adjustment Data Validation. If you identify that the physician didn't document a complication, then you should submit an adjustment transaction to SCAN with 250.00, diabetes without complications.
Q. What documentation would we look for to support the codes 303.90 (other and unspecified alcohol dependence, unspecified drunkeness) and 303.91 (other and unspecified alcohol dependence, continuous drunkenness)?

Dr. is documenting ETOH ½ pint Vodka everyday OR ETOH abuse.

What info will validate these codes if this will not?
A. In the case of "ETOH ½ pint Vodka everyday", nothing can be coded. A coder can't make any diagnosis, and the doctor has just stated how much the patient drinks. He/she hasn't said that there's abuse OR dependence (the codes you are asking about are dependence (i.e., addiction) codes). In order to code addiction/dependence, the physician must document that the patient is addicted or dependent on alcohol. In order to use the fifth digit of "1" the physician must indicate that continuous drunkenness is present.

In the case of the statement "ETOH abuse", then you can only code 305.00, Nondependent alcohol abuse, unspecified drunkenness. The physician has stated that abuse (not dependence) is present. The physician has not specified continuous or episodic drunkenness, so only the unspecified fifth digit of "0" is appropriate.
Q. I am looking for some clarification on how I would code "History of osteomyelitis at 9 yrs of age with residual shortening of the leg" (This pt is 67 yrs old). Would 730.18 (chronic osteomyelitis) +731.3 (major osseous defects) be appropriate?
A. The physician clearly indicated that there is a history of osteomyelitis. It's unlikely that the patient would still have a bone infection 58 years later. The correct coding would be 736.81, acquired unequal leg length, and V13.59, personal history of other musculoskeletal disorders.
Q. I have two separate questions.

What is the correct code for inferior infarct, age undetermined?

If an EKG reads as septal infarct, age undetermined and the physician scratches through the terms abnormal EKG and indicates that the EKG is indeed within normal limits, should the septal infarct still be coded?

Any help that you can provide would be greatly appreciated.
A. In the second instance, it appears as if you're saying that the computer read-out from the EKG says that there's septal infarct, then this cannot be coded. The physician MUST interpret the EKG in order for any coding to take place. I'm also concerned about the statement that the physician "scratches through" the terms. All medical record changes should be done by a single strike through.

If the physician has indeed indicated that he disagrees with an EKG reading, then the abnormality would never be coded. Note, as above, if it's a computer reading, it cannot be coded from in any case.

If in the first instance, you're also referencing a computerized EKG reading, remember that all test results must be interpreted by the physician before coding can happen.

Q: If a physician documents "weakness" in the physical exam for extremities, is that considered enough support for a diagnosis of history of CVA with left hemiparesis for CMS Risk Adjustment?
A. Unless the physician states that the patient has hemiparesis due to/secondary to the CVA, it cannot be coded. CMS Risk Adjustment follows all coding rules and guidelines, including those in Coding Clinic. This issue was addressed in Q1 2005, and the question asked if weakness secondary to a CVA should be coded as hemiparesis secondary to CV
A. CC advised that the correct coding of weakness secondary to CVA is 438.89 (other late effects of cerebrovascular disease) and 728.87, muscle weakness. Physicians should be educated about the need for clear documentation for ICD-9 coding purposes. This is one of the scenarios I use in training, since it's so commonplace.
Q. Can angina still be coded and reported for a patient that is status post stenting?
A. It's appropriate to report angina post stenting only if the patient still has angina. If the stent resulted in resolution of the patient's angina, it should not be reported.
Q. Are hospitalists considered an acceptable physician specialty for risk adjustment purposes? If so what code is used for data collection? EX – General Practice is code 01.
A. Hospitalist isn't a true specialty, rather an explanation of where the physician works. Most hospitalists are internal medicine physicians, although a few are of various other specialties. In order to tell if the physician is an acceptable physician specialty you'll need to look further, perhaps contacting the physician for his/her board certification. Note that neither providers or health plans actually submit the physician specialty codes to CMS at this time.
Q. What if the patient develops complications from tracheostomy scars - like difficulty or pain when swallowing, voice impairment-- because of these ongoing issues can the tracheostomy status code be coded year over year? The physician is reviewing these issues with the patient and documenting in the visit notes.
A. You cannot code for tracheostomy status when the tracheostomy is closed. Tracheostomy status means the patient has a functioning stoma, or opening into the trachea.

If there are complications from an actual tracheostomy, there are codes in the 519.0 series for complications of a tracheostomy. Use of these codes is limited to when the physician documents that a complication of a tracheostomy is present.
Q. I have a question. If a providers documents diagnoses of COPD, but the ICD9 code submited is 491.0 (simple chronic bronchitis). Is this correct coding?

Thank you.
A. No, the physician cannot choose a code more specific than his/her documentation. If the documentation indicates "COPD" it is incorrect coding to call it simple chronic bronchitis when he/she chooses a code. The correct code for a diagnosis of COPD is 496.
Q. One of our providers asked, " What do I document if a patient had atrial fibrillation in the hospital but was cardioverted and doesn't have it anymore? Does the patient still have atrial fibrillation?"
A. What is unclear is whether or not the patient remains on treatment with medication. If the patient is being treated with medication to control their atrial fibrillation going forward, then the atrial fibrillation is under control, not "cured", and it would be appropriate to continue to report it. If the patient is not on ongoing treatment, then the health plan and medical group are entitled only to one year reimbursement (generated by the hospital's submission) of Atrial fibrillation, because the patient no longer has (and is no longer being treated for) atrial fibrillation.
Q: If the provider only documents "DM with renal manifestations" and no mention of the ‘type' of manifestation, can the 250.40 and 583.81 still be coded?
A: No. In that case, you cannot code 583.81—diabetic nephropathy. We can never assume what a problem is. Not all renal complications of diabetes are nephropathy. If you look at the instruction 250.4 you see:

Use additional code to identify manifestation, as:
chronic kidney disease (585.1-585.9)
nephropathy NOS (583.81)
nephrosis (581.81)
intercapillary glomerulosclerosis (581.81)
Kimmelstiel-Wilson syndrome (581.81)

From this, it's clear that more than one renal complication—and this is not an all inclusive list. The physician must document what the complication is. If he doesn't the only thing that can be coded is the diabetes.
Q. What is the criteria for Chronic (Non – Viral) Hepatitis i.e. ICD 9 code 571.40?
A. Coding Clinic, 1993 Q4, indicates that this code is used when there is a diagnostic statement of "active chronic hepatitis". The indication that it is active seems to be important, since most hepatitis caused by medications often resolves when the medication is stopped. When possible, the physician should be queried for more information if the only statement is "chronic hepatitis" since the cause of the hepatitis (medications, alcohol, viral) is important in correct code assignment.
Q. Will a coder consider carpal tunnel syndrome as a peripheral neuropathy? That is, would they code both carpal tunnel syndrome and peripheral neuropathy?
A. No. A coder would never choose to extrapolate from carpal tunnel syndrome, which has its own code (354.0) to a peripheral neuropathy, many of which have their own codes. If a condition has its own code, only that code that should be used. The only exception would be if there is a coding instruction that instructs otherwise.

The codes for peripheral neuropathies include a description and/or diagnosis that informs the coder (and physician) what types of conditions they represent. As you can see, these are quite different from a condition like carpal tunnel syndrome.

356.0 Hereditary peripheral neuropathy
Déjérine-Sottas disease

356.1 Peroneal muscular atrophy
Charcot-Marie-Tooth disease, etc.

I hope this helps.
Q. Once a patient has had a kidney transplant is it correct to still code CKD?
A. It is correct to code CKD if it still exists, and is documented. A transplanted kidney can leave a patient with CKD, but again, the physician must document that CKD exists in order to capture it. You would never assume that the patient has CKD under any circumstances.
Q. From what we have been told the following criteria must be present and documented in order to code major depression:


A major depressive syndrome or episode manifests with five or more of the following symptoms, present most of the day nearly every day for a minimum of two consecutive weeks. At least one symptom is either depressed mood or loss of interest or pleasure
  1. Depressed mood
  2. Loss of interest or pleasure in most or all activities
  3. Insomnia or hypersomnia
  4. Change in appetite or weight
  5. Psychomotor retardation or agitation
  6. Low energy
  7. Poor concentration
  8. Thoughts of worthlessness or guilt
  9. Recurrent thoughts about death or suicide
What happens when the patient is prescribed an antidepressant, and then when there is another encounter, the physician states " patient has major depression which she feels is well-controlled with (the drug). She is able to function without any issues and denies suicidal or homicidal ideations". The physician then reports 296.30 again.

Is this appropriate reporting of this code? Or would the symptoms have to be reported each time? Is the fact that she is taking the medication and that the symptoms were reported initially support the continued use of this code?

Recurrent depression codes to 296.3X, but if the symptoms are being controlled by medication, then there will not be any to report, and this contradicts the criteria requirement. I find this very confusing.
A. In many conditions which are controlled the symptoms that are needed to establish a diagnosis no longer exist. For example, the goal of treating a patient with anti-hypertensive drugs is to bring the patient's blood pressure into normal range. The hypertensive patient who has a blood pressure of 120/80 still has hypertension. If the patient no longer takes their medication, the blood pressure will go up. So, the patient still has hypertension, and the symptom of an elevated blood pressure is merely controlled. A diabetic who has a blood sugar of 100 after their insulin is still diabetic—but doesn't have the symptom of hyperglycemia because the insulin has controlled it.

What you look for in a controlled disease is that the note makes sense—the patient is on a medication (or other treatment, like weekly psychotherapy) that controls the symptoms related to their disease. In this case, the physician not only mentions the medication that the patient is taking, but also a few key things-lack of homicidal/suicidal ideation, the ability to cope with daily life. This demonstrates that the physician is evaluating the symptoms (or lack of symptoms) related to the patient's disease. If this were the visit at which the diagnosis was made, you would look for more. But the documentation you mention seems reasonable for a patient who is being successfully treated for their depression.
Q. The physician has documented "aplastic anemia/ vit B12 deficiency. Recent hemoglobin and hematocrit of 10/29.5 and WBC of 7". While the patient's hemoglobin and hematocrit values have been consistently low over the course of a couple of years, all of her other CBC vales are within normal limits. A previous record from the same physician reads "acquired anticoagulation factor deficiency and pernicious anemia". There is no documentation of more serious bone marrow disorders in any note. Should the physician be queried to provide more supporting documentation regarding his choice of diagnosis of aplastic anemia? Reference I have read state that pancytopenia can be caused by B 12 deficiency. Would that (284.1) be a better choice?
A. Unless the visit was within the past few days, it's too late to query the physician. I don't believe that coding aplastic anemia under these circumstances would be appropriate. It appears that the physician may be thinking "aplastic anemia vs. (/) vitamin B12 deficiency" (pernicious anemia, 281.0). But it doesn't seem like the physician has made a solid diagnosis. Aplastic anemia can only be confirmed by bone marrow biopsy, and there isn't one of those. That doesn't mean that one hasn't been done, but the statements are too unclear. Although we can't code from those earlier diagnostic statements, they do serve to demonstrate that there is some confusion over the actual diagnosis.

We can't make choices like this---nor can the doctor. If he's documented pernicious anemia, but the patient really has pancytopenia, then he cannot choose pancytopenia just because he knows that's what it is...he needs to make an amendment with the correct diagnosis (within a few days) or make a correct and complete diagnosis at the next visit.

I recommend that you educate him/her regarding the documentation issues in this case, and ask for a clear diagnostic statement at the patient's next visit.
Q. If a person has LAD stenosis, but it was stented, do we still code the stenosis?
A. The Official Coding Guidelines address this situation.

“K. Code all documented conditions that coexist
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.”

The purpose of a stent is to ensure that the vessel is patent and that the stenosis no longer exists. If the stenosis no longer exists, it should not be coded.
Q. If the MD writes under one DOS:
Assessment :
Then the following visit he/she writes just COPD, do you capture only the COPD, or code ICD-9: 493.21 (Chronic obstructive asthma with status asthmaticus) on the first date of service, and don’t code the COPD alone for the second visit?
A. In coding, each chart note stands alone. You don’t look back at earlier chart notes to determine how the current one should be coded. You cannot use diagnoses documented at an earlier encounter to supplement the diagnosis in the current encounter. It also seems that you’re assuming that if the physician writes:


that the patient has chronic obstructive asthma with status asthmaticus. That’s not the case. Status asthmaticus is a life threatening condition, characterized by intractable wheezing (e.g. an asthma attack) that does not respond to the usual treatment of bronchodilators and steroids. In order to code 493.21, the physician must state that the patient has chronic obstructive asthma with status asthmaticus, not COPD and asthma.

The correct coding, if both COPD and asthma are documented on the same date, is 493.20 - Chronic obstructive asthma, unspecified. This is because the coding notes for this section of the ICD-9 indicate the following :

“Asthma with chronic obstructive pulmonary disease [COPD]”.

You would not code 496, COPD, because the coding notes for 496 indicate: “Note: This code is not to be used with any code from categories 491-493”
Q. The physician documented: “Intra-Aortic Calcification. Chronic, clinically stable. Recommended statin today. Pt will think about it more and let me know. c/w baby aspirin.”

Does this documentation justify coding 440.0 (atherosclerosis of the aorta)?
A. You have to look at the medical record (the date of service) as a whole in order to know if something can be coded. If this is all of each record, I wouldn’t code them. If this is just the assessment (i.e., the diagnosis), and there is documentation to support each diagnosis, then they could be coded—except probably the first one. “Abnormal GFR” doesn’t mean anything. If a normal GFR is 90-120 then an 89 is “abnormal”, but it doesn’t mean the patient is sick. The physician has to not only write diagnoses, but they have to have support and they have to make sense.
Q. My question is, if the patient has pacemaker implant for SSS or complete AV block, would you code SSS or AV block in addition to V45.01 for Pacemaker status?
A. According to Coding Clinic, 1993, issue 5, not usually:

Although it can be argued that sick sinus syndrome (SSS) is an ongoing condition controlled by a pacemaker, no code assignment is required if no attention or treatment is provided to the condition or device. This differs from the ongoing medication administration provided for conditions such as congestive heart failure, hypertension or diabetes mellitus, and therefore, justifying code assignment. The use of V45.0, Cardiac pacemaker in situ is optional; some facilities will want to code the presence of the device for tracking purposes. Use of code V45 .0 does not imply management of the pacemaker, only its presence.

So, if no treatment is rendered specific to the arrhythmia or the device, no coding should take place. If there is treatment directed at the arrhythmia, then the pacemaker likely is not performing as it should be. If the pacemaker requires reprogramming, then it would be appropriate to code the SSS.
Q: I would like to know some opinions regarding to coding the following documentation by Physician: “ Vascular Dementia”.

In my opinion I’ll use 290.40 plus 437.0. Please see instructional notes “ Use additional code to identify cerebral atherosclerosis”. I need your opinion.

A: You only use an additional code if the condition documented. It’s not something that is automatically done, or done based on what you know about disease processes. Based on your email, the physician only documented vascular dementia. If the physician had said vascular dementia due to cerebral atherosclerosis, then you would code it.

The instructional notes for 250.40 say:
Use additional code, to identify manifestation, as:

chronic kidney disease (585.1-585.9)
nephropathy NOS (583.81)
nephrosis (581.81)
intercapillary glomerulosclerosis (581.81)
Kimmelstiel-Wilson syndrome (581.81)

But you don’t code any of those things unless they are documented. Vascular dementia NOS is indexed to 290.40. In this case, the vascular dementia is not otherwise specified, and you would not assume or code cerebral atherosclerosis.
Q: What are the codes for ASHD due to HTN. Do you consider this a hypertensive heart disease 402.90 or just 414.01, 401.9? Please advise. Thanks
A: I would not code 402.90 unless the physician clearly says hypertensive heart disease or something similar. ASHD is a disease of the vessels leading to the heart, and it is usually caused by HTN, smoking or hypercholesterolemia. The correct coding is 414.01 and 401.9.