Diagnosis Coding: When to Assign a Diagnosis for E/M Services
With the implementation of the AMA (American Medical Association) E/M (Evaluation and Management) documentation guidelines for office and outpatient visits in 2021 (and the pending 2023 E/M guideline changes for emergency department, inpatient, outpatient, nursing facility, and home/residence visits), there has been confusion about when to assign / capture a diagnosis code for E/M services.
Per the ICD-10-CM Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services Guideline J, we should code all documented conditions that coexist:
Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment, or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
Per the AMA E/M documentation guidelines for office and outpatient visits, the definition of a problem is:
A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.
And the definition of a problem addressed is:
A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/ surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.
Confusion appears to arise because of 2 lines in the problem addressed definition, which state:
- Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.
- Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.
Frequently, coders have assigned diagnosis codes managed by another professional or coding for a condition to be addressed by another provider via a referral.
If the provider documents a patient has ESRD but currently is being managed by nephrology, we would not be able to assign this diagnosis as the provider only notes the ESRD without additional assessment or care coordination.
If in the same scenario above for a stable ESRD patient currently managed by nephrology, the provider documents the patient also has diabetes and determines which medication to add to the patient’s regimen. Considering the ESRD medication drug interactions, the provider decides to prescribe Januvia. This is considered management of the ESRD and diabetes, and both conditions would be coded.
Let’s say the provider notes the patient has osteoarthritis of the right knee and refers them to orthopedics for a consultation. Again, we would not assign a diagnosis code as the provider is performing a referral without evaluation or consideration of treatment.
In the same scenario above for a patient with osteoarthritis of the right knee, if the patient presents for a new complaint of right knee pain, the provider takes a history, performs an exam, orders a right knee x-ray, and diagnoses the patient with osteoarthritis of the right knee. Then, the provider refers the patient to orthopedics for a consultation. This would be a referral with evaluation and the osteoarthritis of the right knee would be coded.
One other source to note for diagnosis coding assignment comes from chapter 12 of the Medicare claims processing manual (section 30.6.12.3) which states the following regarding concurrent care:
To support coverage and payment determinations regarding concurrent care, services must be sufficiently documented to allow a medical reviewer to determine the role each practitioner played in the patient’s care (that is, the condition or conditions for which the practitioner treated the patient).
When assigning a diagnosis code for an E/M service, ensure it meets the full definition of a problem addressed per the AMA E/M documentation guidelines, and that a reviewer can determine the provider is treating the patient.
References:
2022 ICD-10-CM documentation guidelines
AMA E/M office and outpatient documentation guidelines
Chapter 12 Medicare claims processing manual