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Old 11-19-2008, 01:38 PM
chandler80 chandler80 is offline
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Default Past Medical History

Is there a list of chronic conditions that is acceptable to code when listed in PFSH/PMH (and often times not mentioned any further in the office note)

Thank you

Last edited by chandler80; 11-19-2008 at 02:07 PM.
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Old 11-21-2008, 02:54 PM
FTessaBartels FTessaBartels is offline
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Default Not treated = Not coded

If the chronic condition is mentioned ONLY in the history and is not being evaluated or treated, then I wouldn't code it.

But perhaps I'm not understanding your question ...

F Tessa Bartels, CPC, CPC-E/M
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Old 11-22-2008, 04:08 PM
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okiesawyers okiesawyers is offline
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I agree with Tessa. A chronic condition or any condition for that matter should only be coded if it is addressed and treated in the A/P. Perhaps I am not understanding your question either. Let us know if we can help further!
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Old 01-17-2009, 08:47 AM
katrinabgood katrinabgood is offline
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I was taught to code chronic conditions such as DM, HTN, and any that might have bearing on what pt is being treated for, such as GERD, COPD, CAD, etc... I have also been told to code all chronic conditions, as it gives "the BIG picture." Is this wrong? (I do ER coding in a hospital.)
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Old 01-19-2009, 12:37 PM
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sthibo sthibo is offline
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Smile Guidelines

According to the ICD-9-CM Guidelines, Section IV-k, 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. I hope this helps. You can find a lot of answers to questions in the Guidelines!
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Old 01-19-2009, 02:42 PM
FTessaBartels FTessaBartels is offline
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Default Whose the doctor?

I did not examine the patient. I did not take the history. I'm not a doctor (or any other healthcare provider). I don't know if the DM mentioned in the history has any impact on the broken ankle unless the doctor states so in the documentation.

If it's just in the history section with no further mention, I don't assign a Dx code.

The provider should document what was done. The coder should code what was documented.

F Tessa Bartels, CPC, CEMC
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Old 01-19-2009, 04:05 PM
katrinabgood katrinabgood is offline
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Thanks, sthibo! That's what I thought, but it certainly wouldn't hurt me to review the guidelines periodically!
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