Wiki Pulling from Problem List

[SavannahMor]

I know a diagnosis code can be used if problem is documented on or before the date of service, but how far are we able to go back into the patient's chart for this information?

 

[thomas7331]

I know a diagnosis code can be used if problem is documented on or before the date of service, but how far are we able to go back into the patient's chart for this information?

Coders may only assign ICD-10 codes from the documentation of the current encounter. Per the ICD-10 guidelines, a diagnosis requires provider's documentation that the condition exists at the encounter and requires or affects treatment. A coder cannot assume that because a patient had a condition in the past or because it is in a problem list from a prior encounter that the condition still exists, unless the provider has stated so.

 

[Coder90]

Coders may only assign ICD-10 codes from the documentation of the current encounter. Per the ICD-10 guidelines, a diagnosis requires provider's documentation that the condition exists at the encounter and requires or affects treatment. A coder cannot assume that because a patient had a condition in the past or because it is in a problem list from a prior encounter that the condition still exists, unless the provider has stated so.

What if the patient is being treated for CKD and hypertension is mentioned in the problem list? However, hypertension is not documented in the encounter.

 

[thomas7331]

What if the patient is being treated for CKD and hypertension is mentioned in the problem list? However, hypertension is not documented in the encounter.

If your provider keeps the problem lists current and there's documentation that they reviewed and updated it at the encounter, then I would be comfortable coding from that.

But this is an area where your organization should give you some guidance. Problems lists work differently in different EMRs and providers use them differently from practice to practice, so someone who's familiar with what's going on in your particular practice should direct you on this. I've had the experience in my work that many problem lists are not kept up to date by the providers. Also, if the provider has not mentioned those conditions in their documentation then it shouldn't really be up to a coder to decide, for example, what medication is treating what condition if it isn't clearly documented unless your practice gives you that training. But in my opinion, unless you're coding in a facility where medications or treatments are being administered at that encounter and you have current orders on file, it's not really a good idea to assume that a patient is being treating for anything unless the provider's current encounter documentation supports it.