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Risk Coding

Risk Coding Tip – Sept 2022

While risk coding may not play an obvious role in preventing ED visits, accurate coding and thorough documentation ensures that patients with chronic medical and behavioral health conditions are identified and have access to payer-supported resources to help manage those conditions.

Here are some diagnosis codes that, when appropriately coded to the higher specificity, help to identify those patients who may require complex patient care management:

  • Diabetes with hyperglycemia (E11.65) versus Diabetes, uncomplicated (E11.9)
  • Chronic kidney disease stage 5 (N18.5) versus Chronic kidney disease (unspecified)
  • Opioid dependence (F11.20) and Chronic pain syndrome (G89.4) versus Low back pain (M54.5)
  • COPD (J44.9) versus Moderate persistent asthma, uncomplicated (J45.0)
  • Major depressive disorder, recurrent, moderate (F33.1) versus Depression (F32.A)

Select the diagnosis code that provides the most information about the patient’s condition.

  • Instead of Anxiety (F41.9), select a further specified diagnosis that discusses the root of the patient’s condition:

    – Bipolar disorder, current episode, mixed, mild (F31.61)
    – Bipolar II disorder (F31.81)
    – Borderline personality disorder (F60.3)
    – Other specific personality disorder (F60.89)
    – Other childhood emotional disorders (F93.8)

  • Instead of Headache, unspecified (R51.9), select a further specified diagnosis that clarifies the nature of the headache:

    – Migraine, unspecified, not intractable, without status migrainosus (G43.909)
    – Periodic headache syndromes in child or adult, not intractable (G43.C0)

Using these codes places your patients in the proper “bucket” and/or outreach call list to make sure that these patients are being seen by their primary care providers and having their chronic conditions managed in a more efficient and cost-effective venue.