Coding for Chronic Condition Management

Coding for Chronic Condition Management

If you are a medical coder and you find that coding chronic conditions is a bit confusing, don’t feel bad- you’re not alone. Even professional coders who have been in the industry for years get it wrong every now and then. In order to get though it though, it’s critical to understand that it’s not enough to see the words “ongoing”, “over the past several/few years”, or “for the last 6 months.” You must also dig a bit deeper and learn the criteria that surrounds the patient’s chronic condition.

In order to clear this up, let’s take a look at some examples of chronic clinical conditions.

Headaches and Migraines: Coding for Chronic Condition Management

According to the National Headache Foundation, around 28 million Americans suffer from migraines. A higher percentage of women than men suffer from these and about ¼ of women who have migraines end up having 4 or more every month. A migraine can last for a few hours to a few days- and sometimes even longer.

The diagnostic codes for migraines classifies them by type.

  • Hemiplegic Migraines: a very rare, serious type of migraine. Symptoms can be slightly concerning to completely debilitating and the severity varies with each episode. The patient may have extreme pain and minor paralysis during one and in the next have minor pain with extreme paralysis during the next. Symptoms of a hemiplegic migraine lasts from 5 minutes to an hour.
  • Chronic Migraines: according to the National Headache Society, chronic migraine is defined as migraines that occur 15 or more days per month for at least 3 months.
  • Persistent Migraines: this type of migraine lasts for 3+ months and occurs every day from within 3 days of it beginning.
  • Ophthalmoplegic (ocular) Migraines: with this type of migraine, the patient has pain around their eyes and may be unable to move their eyes. In addition, they will have dilated pupils. This type of migraine is rare and commonly occurs in children.
  • Menstrual Migraines: caused by estrogen and typically occur before, during, or after ovulation or menstruation.
  • Abdominal migraines: very rare in adults- typically affecting only children between the ages of 5-9. These are difficult to diagnose because the patient may only have pain in their abdomen, without head pain- and children don’t always know how to express what is going on.

In these cases, the physician may state that the patient has had migraines for several years and are tension migraines. In this case, the patient is actually experiencing tension headaches, not chronic migraines.

Since a chronic migraine must occur 15 or more days per month for at least 3 months, according to the International Headache Society, you can see why more information is needed to code the diagnosis for billing purposes.

Otitis Media

This is a very painful condition in which the patient has symptoms of redness in their eardrum, fever, and pus in the ear. Acute otitis media is considered to be the most common form of ear infection, occurring behind the tympanic membrane in the middle ear. In some cases, the symptoms are treated without antibiotics. However, in some other cases, antibiotics are prescribed for the treatment of this condition.

According to the National Institute of Health, ¾ children have at least one ear infection before they reach the age of 3. Unfortunately, this is a common, recurring issue for many children, with about 1/3 of children having more than 6 ear infections before they reach the age of 7. This is the 2nd most common childhood condition- upper respiratory infections are first on this list.

Let’s look at this example:

Effusion with otitis media: build-up of fluid without signs/symptoms of infection, caused by infections or exposure to irritants, and does not typically respond to antibiotic treatment.

If a patient visits his physician for a otitis media follow-up and was treated one month prior to this and a similar episode 2 years ago, there are certain criteria that must be met for this to be considered a chronic condition.

  • Acute
  • Persistent (relapse within 1 month)
  • Recurrent (3+ within 6-18 months)
  • Chronic (persistent & recurrent)

Based on this criterion, the patient in the above example has a persistent case, not a chronic one.


This is a condition that is characterized by inflammation of the sinuses. This can be due to fungal, bacterial, or viral infections. Most of the time, a sinus infection is caused by a virus. Some other causes are allergies, structural problems in the nasal cavity, weakened immune system, or pollutants. According to the experts, around 35 million people suffer from sinusitis, which contributes to 16 million office visits annually.

Let’s take a look at this example:

A patient visits her physician for a case of sinusitis that she’s been fighting for almost 3 months. She’s not able to get relief and symptoms present today as if she has not recovered- she tells her physician she needs another round of treatment.

According to the AOA-HNS criteria, this patient is considered to be subacute. If the condition lasts 4 weeks or less, it’s considered acute. If it has lasted 4 to 12 weeks, it is considered subacute. If it has lasted 12 or more weeks, it is considered chronic- with or without being exacerbated. If you have 4+ episodes in a year, the condition is considered to be recurrent acute.

This is also in alignment with the CDC’s overview of a sinus infection. Acute bacterial sinusitis can last for up to four weeks & subacute bacterial sinusitis can last for up to 12 weeks, but occurs 4 times or less per year. Typically, chronic sinusitis will last for more than 4 weeks and presents more than 4 times a year.

When you take the time to understand chronic care management codes, you re much less likely to end up latching onto simpler terms and assuming they are clinically significant. Be sure to stay in contact with the physicians you are working for to keep everyone on the same page, working towards the common goals of remaining compliant in documenting and coding.

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