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kwatson0

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Can someone help with Anemia, Provider stated stable anemia D64.9 continue Iron Medication, Auditor states I should use history of (Z86.2) and I disagree . What are your thoughts?
 
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Anemia is a chronic condition. The patient's anemia appears stable as there appears to be no change in the treatment regimen based on what you provided. The patient is still being treated with iron. The condition still exists rather than a history of. Unless I missed a guideline change, based on what you provided above, the condition is still coded as a current chronic condition,
 
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dniece70 said:
Anemia is a chronic condition. The patient's anemia appears stable as there appears to be no change in the treatment regimen based on what you provided. The patient is still being treated with iron. The condition still exists rather than a history of. Unless I missed a guideline change, based on what you provided above, the condition is still coded as a current chronic condition,
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Thank you,patient was diagnosed 3 months ago, Provider did not state chronic am I missing a guideline?
 
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kwatson0 said:
Thank you,patient was diagnosed 3 months ago, Provider did not state chronic am I missing a guideline?
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dniece70 gave an excellent concise response.

I would say, though, that whether the anemia is chronic or not, it is still an active condition. The fact that the provider called it "stable" and pt is to continue taking iron supplements, show that it is active and not a hx of.
 
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lgardner said:
dniece70 gave an excellent concise response.

I would say, though, that whether the anemia is chronic or not, it is still an active condition. The fact that the provider called it "stable" and pt is to continue taking iron supplements, show that it is active and not a hx of.
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Thank you I agree don't know why I was dinged by auditor , how would you look at Anemia if D64.9 DOCUMENTED TO Assessment no mention of stable but states Hemo in house labs normal. Would you consider that hx of?
 
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kwatson0 said:
Thank you I agree don't know why I was dinged by auditor , how would you look at Anemia if D64.9 DOCUMENTED TO Assessment no mention of stable but states Hemo in house labs normal. Would you consider that hx of?
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I, also, don't know why you would have been dinged. I would question the auditor (if possible). they might have been having an 'off' day, auditors are human, too. ;)

as far as your new example, if the provider is having the pt continue taking iron, then I would consider it active, unless the provider states that it is hx.

ALSO, keep in mind that we cannot code based on the lab results, but we can use them to query a provider.
for example, "a dx of E11.65 - 'DM 2 with hyperglycemia' was assessed on 'DOS'. impression states "stable and continue metformin at current dose", but pt's latest A1c (DOS) was 6.0. please confirm that E11.65 is the appropriate dx".
 
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When coding a history of, the condition was either treated and no longer exists. If the patient is still taking medication for the condition, it does not qualify as a history of the condition. It's in the ICD-10 guidelines.

Chapter 21.c.4 History (of)
"...Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require monitoring."
 
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Hi KWatson :)
I agree with all above but why use dx D64.9 better to use D50.9 Iron Deficiency Anemia? I do not agree using dx Z86.2 history code unless provider stated in the past and cured. Pt still taking meds means still has the condition of Iron Deficiency . I think auditors can make mistakes too.
Lady T:)
 
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TThivierge said:
Hi KWatson :)
I agree with all above but why use dx D64.9 better to use D50.9 Iron Deficiency Anemia? I do not agree using dx Z86.2 history code unless provider stated in the past and cured. Pt still taking meds means still has the condition of Iron Deficiency . I think auditors can make mistakes too.
Lady T:)
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If the provider only documented "stable anemia", the only code that would be appropriate would be D64.9. D50.9 is not supported by the documentation provided. ;)
 
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TThivierge said:
Hi
Ok but the provider is giving the patient Iron Deficiency medications per note above.
Lady T
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but we, as coders, cannot use medication to assign a code.

I might query the provider, in this situation, but a coder could not assign Iron Deficiency anemia, if the documentation only states "stable anemia, continue iron medication"
 
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