Coding accuracy depends on specificity in both documentation and code selection. Following are reminders on coding guidelines for reporting the correct phase of an illness and differentiating between current and historical conditions.

Illness Phases

In order for the code selection to accurately match the records, it’s important to apply the coding guidelines for reporting acute conditions, sequela (i.e., late effects) and resolved or historical conditions. Improper coding of the phase of illness may affect the accuracy of your patient’s reported condition and the validity of the diagnosis.

• Acute codes are used for a condition that currently exists on an acute basis. In many cases, such as myocardial infarction (MI) or cerebral infarction, these conditions usually develop suddenly and require emergent care.
• Sequela codes are reported when treating the residual effects from an initial illness or injury. There are no time limits on when these codes may be used. The code for the acute phase of the condition is never used with the resulting sequela code.
• History codes are used when the condition has been resolved, and no further treatment is required. Failure to properly use a history code results in reporting a condition that no longer exists.

Examples

Stroke 

• The acute diagnosis code for a stroke is used only for the initial inpatient encounter.
• Encounters for treatment of neurological deficits caused by cerebrovascular disease are reported with a sequela code.
• When there are no neurological deficits present, a personal history of cerebral infarction should be reported for subsequent encounters.

Myocardial Infarction

• The acute diagnosis code for an MI is reported for the initial encounter and for encounters occurring during the following 28 days. Additional infarctions occurring during the 28 days should be reported as a subsequent MI.
• Encounters for related treatment occurring after the 28-day period should be reported with an aftercare code.
• A historical MI not requiring additional treatment is reported as an old MI.

Fractures

• Coding for fracture care utilizes the same code category for each phase (initial, subsequent, and sequela) but requires selection of a seventh character to describe the episode of care and healing status of the fracture.
• The personal history of fracture status codes are used to report a healed fracture.

Learn more

Visit Provider Education and Assessment Tools page on the Cigna Healthcare Medicare Advantage Providers website (MedicareProviders.Cigna.com) for additional resources.

Providers must confirm the accuracy of reported diagnoses and ensure that their practices comply with the ICD-10-CM Official Guidelines for Coding and Reporting and applicable legal requirements. Accurate and complete documentation, coding, and submission activities allow Cigna Healthcare Medicare Advantage plans to provide quality care and resources to your patients. If you believe any codes were previously submitted in error, contact your Provider Education specialist, or email ProviderEducation@CignaHealthcare.com.

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