Health Information Management

Q/A: Severity of illness and APCs

APCs Insider, March 20, 2010

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Does severity of illness affect APC reimbursement under the hospital OPPS as it does under the MS-DRG system? This is what we’ve been told, but we are unable to find any Medicare resource that indicates this is so.


A: Physicians and practitioners need to document medical conditions, signs, symptoms, and diagnoses to the greatest level of specificity for all outpatient encounters. Simply, the physician documents the patient’s severity of illness while the clinical staff documents the intensity of services.

Physicians document the severity of illness for outpatient cases by diagnosis(es). Coders assign ICD-9-CM diagnosis(es) to complete the picture or story of the outpatient encounter. This consistent process strengthens the outpatient case mix and justifies the medical necessity of outpatient services to include diagnostic tests, therapeutic services, and observation services. Furthermore, outpatient coding guidelines in the introduction to the ICD-9-CM Manual, Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services state:
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. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
The word affect is synonymous with influence. Therefore, treatment for the chronic conditions during an outpatient encounter are not necessary. Physician documentation of chronic conditions ( i.e. diabetes, COPD, CAD, hypertension) during an ED or ambulatory encounter indicates that they are present and accounted for with respect to how they influence the current care/ treatment of the patient.

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