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nyyankees

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If a diagnosis is mentioned in the note - HPI (i.e. knee pain 719.46) but NOT mentioned in the Assesment section of the note can I capture the 719.46 knee pain on the claim?
 
Is the treatment plan addressing the knee pain (i.e. OTC pain meds, etc) or is there documentation that shows the knee pain affected the physician's decision to treat the other problem(s) that the patient has? If it is just a matter of documenting knee pain in the HPI but nothing else in the documentation addresses it, then no, I would not code this.
 
MnTwins29 said:
Is the treatment plan addressing the knee pain (i.e. OTC pain meds, etc) or is there documentation that shows the knee pain affected the physician's decision to treat the other problem(s) that the patient has? If it is just a matter of documenting knee pain in the HPI but nothing else in the documentation addresses it, then no, I would not code this.
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Ok - so if doc documents pain in 3 separate areas in HPI but only treats 1 area you code only capsture that 1 area? But if the other 2 areas affect the plan and treatment of that 1 area you can capture all 3?

Just want to make sure. Thanks..
 
nyyankees said:
Ok - so if doc documents pain in 3 separate areas in HPI but only treats 1 area you code only capsture that 1 area? But if the other 2 areas affect the plan and treatment of that 1 area you can capture all 3?

Just want to make sure. Thanks..
Click to expand...

Okay, let's try this - to make sure I undertand you. Now, these are unrealisitic medical situations - but I am doing this to try to illustrate how I understand your question.

Pain in 3 areas documented in HPI - so let's say that the patient has ear pain, shoulder pain and Knee pain (your original question). Doctor documents that he treats ear pain only, with an antibiotic. Nothing else about the shoulder or knee. With that, I would only code the ear pain.

Now, if the patient is already taking something for the shoulder and knee pain, but what he wants to prescribe for the ear pain would cause a drug intereaction, now the shoulder and knee pain would affect the treatment of the ear pain - and thus would be coded, as these did affect the final treatment plan of the ear pain.

Like I said, this isn't realistic, but does it illustrate what you are trying to ask?
 
MnTwins29 said:
Okay, let's try this - to make sure I undertand you. Now, these are unrealisitic medical situations - but I am doing this to try to illustrate how I understand your question.

Pain in 3 areas documented in HPI - so let's say that the patient has ear pain, shoulder pain and Knee pain (your original question). Doctor documents that he treats ear pain only, with an antibiotic. Nothing else about the shoulder or knee. With that, I would only code the ear pain.

Now, if the patient is already taking something for the shoulder and knee pain, but what he wants to prescribe for the ear pain would cause a drug intereaction, now the shoulder and knee pain would affect the treatment of the ear pain - and thus would be coded, as these did affect the final treatment plan of the ear pain.

Like I said, this isn't realistic, but does it illustrate what you are trying to ask?
Click to expand...

Yes - exactly. Thanks again..
 
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