Question: I am unsure what ICD-10 diagnosis codes should go on a claim for an encounter.  Here is an example: a patient is seen for a nagging cough/cold symptoms.  Since the patient has hypertension, the doctor told her there are certain over-the-counter medications she should not take.   He then gives her examples of ones she should take.  He is not treating her high blood pressure at the visit, though, so I am not sure if I should code it or not.

 Answer: Great question!  Guideline IV.J of the ICD-10-CM Official Guidelines states, “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.” So, in your example, the hypertension was not being treated at the visit, but the presence of the disease did affect management of the condition that was treated.  The hypertension should be reported on the claim form but not as the first-listed code as it was not the focal point for the visit.  Hope this helps.

*NOTE: This response is current in April 2024.  As guidelines and payor guidance may change, please be sure to check if it is still valid when you are reading this issue.

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