Q&A: Integral conditions
Q: I'm struggling to better understand coding “integral conditions.” Can you help me?
A: The Official Guidelines for Coding and Reporting do not specifically define what is an integral condition. The provider has some discretion in determining this and, if you aren’t sure, you should query the provider.
The rules say that coders should not assign a code for conditions that are an integral part of a disease process. Signs and symptoms that are associated routinely with a disease should not be assigned as additional codes, unless otherwise instructed by the classification.
For example, think about shortness of breath (SOB) or dyspnea and chronic obstructive pulmonary disease (COPD) exacerbation. Since the symptoms of SOB or dyspnea are inherent or typically occur during an exacerbation event, these symptoms would not be reported as separate codes.
On the other hand, if the symptoms are not common or considered inherent to the condition, they should be coded separately. For example, consider a patient admitted with a urinary tract infection (UTI) who is also demonstrating dyspnea. In this case, we would report both the UTI and the dyspnea as most patients with a UTI do not demonstrate dyspnea.
The AHA Coding Clinic for ICD-10-CM/PCS does offer some guidance in this area. For example, past Coding Clinics have addressed encephalopathy related to seizures and hypoglycemia. The most famous is Coding Clinic for ICD-9-CM, Third Quarter, 1991. It deals with pleural effusions and heart failure and says that:
Pleural effusion is commonly seen with congestive heart failure with or without pulmonary edema. The pulmonary veins and lymphatics drain the pleural space and return fluid to the heart. In left heart failure, which results in elevated pressures in the venous system, there is usually some accumulation of fluid in the pleural space. Ordinarily the pleural effusion is minimal and is not specifically addressed other than by more aggressive treatment of the underlying congestive heart failure. In this situation it should not be reported unless the coder is directed to do so by the physician.
The last consideration when it comes to integral conditions is well explained in the same Coding Clinic related to heart failure and pleural effusion. It speaks to the fact that there are times when an integral condition can be reported with a separate code:
Pleural effusion documented only as an x-ray finding without the physician having made such a diagnosis should not be reported. Occasionally, however, special x-rays such as decubitus views are required to confirm the presence of pleural effusion, or a diagnostic thoracentesis may be performed to identify its etiology. In other cases, it may be necessary to address the effusion by therapeutic thoracentesis or chest tube drainage. In any of these situations, it is acceptable to report pleural effusion (511.9) as an additional diagnosis since the condition was specifically evaluated or treated, but reporting is not required.
When struggling to determine when to report a condition or when it might be integral to a condition, follow the coding conventions, Official Guidelines for Coding and Reporting, and relevant advice from Coding Clinic. If there are no specific instructions, a query may be needed.
It may also be helpful to consider these critical thinking questions:
- Does everyone with this condition also demonstrate this presentation or symptoms? (i.e., is this a classic finding for this disease process?)
- Were there any treatments or interventions applied related to this finding that are out of the ordinary or not usually performed?
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at firstname.lastname@example.org. For information regarding CDI Boot Camps, click here. This article was originally published in July 2019 and has been updated to reflect the newest coding and documentation guidelines.