Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition.
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.
When should chronic conditions which are treated on an ongoing basis be coded?
Chronic diseases that are treated on an ongoing basis should be coded and reported as often as the patient receives treatment and care for the chronic conditions. In the physician office it is acceptable to code V codes as a first-listed diagnosis.
What describes conditions that remain after a patient’s acute?
A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury.
What should you code when a definitive diagnosis has not been established?
T/F – Codes that describe symptoms and signs are acceptable for coding when a definitive diagnosis has not been established in a physician’s office. T/F – If signs and symptoms exist that are not routinely associated with a disease process, the signs and symptoms should not be coded.
Can you code a probable diagnosis?
If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it existed or was established.