CRC ICD-10-CM Coding Guidelines 2 — Questions and Answers
Question 1: When a provider documents 'suspected' or 'probable' condition in an outpatient encounter, how should the coder handle this for risk adjustment?
- Code the suspected condition as confirmed
- Code only signs, symptoms, or findings — never code suspected conditions in outpatient settings (Correct answer)
- Code both the suspected condition and symptoms
- Query the provider before coding anything
Correct answer: Code only signs, symptoms, or findings — never code suspected conditions in outpatient settings
Section IV.H states uncertain diagnoses should NOT be coded in outpatient settings. Code to the highest degree of certainty.
This is critical for risk adjustment since most MA encounters are outpatient. Coding uncertain conditions as confirmed violates Official Guidelines.
Question 2: How is the causal relationship between diabetes and a complication established under ICD-10-CM guidelines?
- Provider must explicitly state 'due to diabetes' for every complication
- ICD-10-CM assumes a causal relationship for certain conditions unless provider documents otherwise (Correct answer)
- Each complication needs a separate linkage code
- Only complications developing after the diabetes diagnosis qualify
Correct answer: ICD-10-CM assumes a causal relationship for certain conditions unless provider documents otherwise
Section I.C.4.a.6 presumes a causal link between diabetes and certain listed conditions unless the provider documents a different cause.
A diabetic patient with retinopathy is presumed to have diabetic retinopathy unless the provider documents otherwise. This significantly impacts HCC capture.
Question 3: A provider documents 'bilateral knee osteoarthritis.' What is the correct coding approach?
- Code M17.0 for bilateral primary osteoarthritis (Correct answer)
- Code M17.11 and M17.12 separately
- Code M17.9 for unspecified knee
- Query the provider for the primary side
Correct answer: Code M17.0 for bilateral primary osteoarthritis
ICD-10-CM provides a specific bilateral code (M17.0) for knee osteoarthritis. When available, use the bilateral code.
Coding approach depends on what the classification provides: bilateral code if available, or separate right/left codes if not.
Question 4: When should Z-codes be used as the principal or first-listed diagnosis?
- Z-codes can never be principal
- When the encounter is specifically for the purpose described by the Z-code, such as screening or aftercare (Correct answer)
- Z-codes are always secondary
- Only Z-codes for BMI and blood type can be first
Correct answer: When the encounter is specifically for the purpose described by the Z-code, such as screening or aftercare
Certain Z-codes can be principal when the encounter is specifically for that purpose: immunization, screening, aftercare, etc.
Some Z-codes like transplant status or amputation status map to HCCs. Correct sequencing ensures accurate identification.
Question 5: When coding acute and chronic conditions for the same condition, what does Section I.B.8 require?
- Code only the acute condition
- Code only the chronic condition
- Code both with the acute code sequenced first, unless a combination code exists (Correct answer)
- Code only a combination code
Correct answer: Code both with the acute code sequenced first, unless a combination code exists
If separate codes exist, code both with acute first. If a combination code exists (like acute-on-chronic heart failure), use that instead.
Acute and chronic conditions may map to different HCCs, making this distinction important for risk adjustment.
Question 6: A chart documents 'history of DVT, currently on anticoagulation.' How do guidelines distinguish history from active conditions?
- If on medication, always code as active
- The provider's documentation determines status; 'history of' uses Z-codes unless the condition is documented as active (Correct answer)
- History codes are never used with medication
- The coder independently determines based on medication review
Correct answer: The provider's documentation determines status; 'history of' uses Z-codes unless the condition is documented as active
The provider's documentation drives the decision. History codes generally do not map to HCCs, while active condition codes often do.
A patient on warfarin for DVT prophylaxis may have resolved DVT (Z-code) or active DVT (I82.x with HCC value). The coder follows documentation.
CRC ICD-10-CM Coding Guidelines 2
When a provider documents 'suspected' or 'probable' condition in an outpatient encounter, how should the coder handle this for risk adjustment?