Medical coders have to follow different set of guidelines for coding diagnosis. The diagnosis can be reported with the help of medication or drug as well documented in the medical report. Yes, use of drugs are very common for patients with chronic illness. Hence, the chronic diseases also need to reported while reporting other primary diagnosis, since these diseases also needs physician attention during treatment.

Poisoning, adverse effects, drug use and abuse and underdosing of drugs are also reported with ICD 10 codes following coding guidelines. But, in this article we will focus on the medication or drug information that are missed or unnoticed by medical coders in the documentation. Let us understand this with a small example.

A surgeon is treating a patient for an ankle fracture and focuses only on that acute condition. But, the report also documents the chronic conditions like diabetes, hypertension, CKD which are left unnoticed.

Chronic conditions are conditions that may be under control but require medication. These chronic condition can create a problem for treatment of fracture, hence the surgeon first needs to take care of these chronic condition. Hence, these chronic condition should also be reported as secondary diagnosis.

Today, we will checkout the different Chronic conditions and drugs used to keep them under control.

Read also: When to use hydration CPT code 96360 & 96361

Hypertension and it Drugs

Hypertension, the medical term for high blood pressure, is known as “the silent killer.” It is a persistent elevation in blood pressure that puts additional strain on the heart. Abnormal pressures are greater than 140 mmHg systolic pressure and are greater than 90 mmHg diastolic pressure.

Different types of drugs like alpha blocker, alpha-beta blockers, ACE inhibitors, beta blockers, calcium channel blockers etc. help in controlling the blood pressure. Hypertension can be controlled with the help of different drugs, some of them are listed below.

• Doxazosin (Cardura)
• Prazosin (Minipress)
• Terazosin
• Carvedilol (Coreg)
• Labetalol
• Benazepril (Lotensin)
• Captopril (Capoten)
• Enalapril (Vasotec)
• Fosinopril (Monopril)
• Lisinopril
• Ramipril (Altace)
• Irbesartan (Avapro)
• Losartan (Cozaar)
• Valsartan (Diovan)

Asthma & COPD

Asthma a chronic condition that causes inflammation and narrowing of the bronchial tubes, the passageways that allow air to enter and leave your lungs. Symptoms of asthma include wheezing, chest tightness, trouble breathing, and coughing.

Chronic obstructive pulmonary disease (COPD) is the name for a group of lung conditions that cause breathing difficulties. It includes: emphysema – damage to the air sacs in the lungs. chronic bronchitis – long-term inflammation of the airways.

There are different Bronchodilators, Antiinflammatory drugs (Corticosteroids) drugs which are used for controlling asthma and COPD. Some of these drugs are listed below.

• Dexamethasone (Decadron)
• Methylprednisolone (Medrol)
• Budesonide (Pulmicort)
• Fluticasone (Flovent)
• Triamcinolone (Azmacort)
• Albuterol (Proventil)
• Ipratropium (Atrovent)
• Levalbuterol (Xopenex)
• Formoterol (Foradil)
• Salmeterol (Serevent)

• Tiotropium (Spiriva)
• Budesonide/formoterol (Symbicort)
• Fluticasone/salmeterol (Advair)

Read also: Role of CDI Specialist in Medical coding

Congestive Heart Failure

 Congestive Heart Failure (CHF) occurs when the heart is unable to pump blood fast enough, resulting in swelling, shortness of breath, and other issues.

Diuretics, ACE inhibitors, calcium channel blockers drugs are used for CHF treatment. Some of the them are listed below.

•  Digoxin (Lanoxicaps, Lanoxin)
• Bumetanide
• Chlorothiazide (Diuril)
• Chlorthalidone (Hygroton)
• Furosemide (Lasix)
• Hydrochlorothiazide (Microzide)
• Spironolactone (Aldactone)
• Torsemide (Demadex)
• Captopril
• Enalapril (Vasotec)
• Fosinopril
• Lisinopril
• Ramipril (Altace)
• Amlodipine (Norvasc)
• Diltiazem (Cardizem)
• Verapamil (Calan SR)

Read also: Best coding guide for Acute versus Chronic Condition

Hyperlipidemia

Hyperlipidemia (also known as high cholesterol) refers to several disorders that can result in too much fat (lipids) in the blood. Cholesterol is one type of fat or lipid.

Below are the drugs used for the treatment of hyperlipidemia.

• Alirocumab (Praluent)
• Atorvastatin (Lipitor)
• Colesevelam (Welchol)
• Ezetimibe (Zetia)
• Fluvastatin (Lescol)
• Gemfibrozil (Lopid)
• Lovastatin (Mevacor)
• Pravastatin (Pravachol)
• Simvastatin (Zocor)

Depression

Depression is more than just a low mood – it’s a serious mental health condition (mental illness) that has an impact on both physical and mental health.

Below drugs used for controlling depression or low mood.

• Amitriptyline (Elavil)
• Bupropion (Wellbutrin)
• Citalopram (Celexa)
• Duloxetine (Cymbalta)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Phenelzine (Nardil)
• Sertraline (Zoloft)
• Venlafaxine (Effexor)

Arrhythmia

Any irregularity in your heart’s natural rhythm is called an arrhythmia. It is also known as arrhythmia, dysrhythmia, or irregular heartbeat.  It affects  the rate or rhythm at which the heart beats.

Below are the list of some drugs used for treating Arrhythmia

• Amiodarone (Cordarone or Pacerone)
• Disopyramide (Norpace, Norpace CR)
• Dofetilide (Tikosyn)
• Flecainide (Tambocor)
• Metoprolol (Lopressor)
• Procainamide
• Propafenone (Rythmol)
• Quinidine
• Sotalol (Betapace or Sorine)

Gastroesophageal reflux disease (GERD)

Gastroesophageal reflux disease (GERD), or just acid reflux, is when stomach acid frequently flows back into the esophagus.

The most common symptom of gastroesophageal reflux disease (GERD) is regular heartburn, a painful, burning feeling in the middle of your chest, behind your breastbone, and in the middle of your abdomen. 

Below are the list of some drugs used for treating GERD.

• Esomeprazole (Nexium)
• Famotidine (Pepcid)
• Lansoprazole (Prevacid)
• Omeprazole (Prilosec)
• Pantoprazole (Protonix)
• Rabeprazole (Aciphex)
• Ranitidine (Zantac)