Capturing dx codes from problem list?

momo2

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Hello,

I am reviewing the CRC study guide for my eventual test. I came across a test question on one of the practice exams which looked like this:

Within the progress note it stated:

PMH:

Medical Problems:

Hypertension, Atrial Fibrillation, Non-insulin Dependent Diabetes

Current Meds: Indomethacin 50 mg. Lanoxin 0.125 mg. Iron 325 mg. Lasic 40 ma Glyburide 2.5mg. Xalatan 0.005 %. Synthroid 125 meg, Lisinopril 40mg, Mag-Tab SR 84 mg. Ditropan 5 mg, Vitamin B-^ 50 mg.

Assessment:

#1 Atrial Fibrillation - on digoxin - Plan = Med Current: Lanoxin 0.125 mg 1 po q d

#2 Arthritis Climacteric Multiple Sites - Plan = Med Current: indomethacin 50 mg take as needed

#3 Congestive Heart Failure Unspecified - Comments: digoxin, no edema

#4 Insomnia

#5 Adjustment Disorder with Depression - Comments: situational, with sleep issues. Med Current: Remeron 15 mg 1 po hs

#6 Cough - Comments: Has infiltrates vs CHF on CXR's. CXR next week


Choice Answers:

A. I48.91, M13.89, I11.0, I50.9, G47.00, F43.21, R05, E11.9, Z79.84

B. I48.91, M12.9, I50.9, G47.00, F32.9, E11.9, Z79.4, R05

C. I48.91, I50.9, F43.21, G47.00, E11.9, Z79.84

D. I48.91, M12.9, I10, I50.9, G47.00


The correct answer is A.

Question#1: I would like to know what risk adjustment guidelines state as far as "linking" the "Diabetes and Hypertension" mentioned within the "Medical Problems" listed above with the CHF and why the Diabetes was allowed to be included.

Question#2: Since the Hypertensive Heart Failure code (E11.0) and the Diabetes code (E11.9) are also appropriate to code, how does this affect an E/M note.....if the HTN and DM are not under the assessment and plan, wouldn't an insurance company ding a provider if they included these codes for which there is no stated assessment and plan?

I hope this isn't too confusing, but I am working in a risk adjustment position at the moment but also am a former E/M coder and am conflicted with this scenario.

Any help clarifying this situation is greatly appreciated.

Thanks!!
 
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The glyburide and lisinopril are listed in the Current Med list so those are TAMPER in risk adjustment coding to allow Diabetes and Hypertension to be made current diagnoses. The Hypertension and CHF are linked due to the updated ICD-10 guidelines as of 10/01/2016 to current date - see the Htn section in the ICD-10 manual coding guidelines. Part of HCC/Risk Adjustment coding is assessing the provider's note to read other diagnoses that are being treated that are not mentioned in the Assessment and Plan. Lab results, HPI notations, Current Med lists, and other information in the note above the Assessment can be used to make a diagnosis in the pmh/Prob List current.
 

momo2

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Thanks for your response....just one questions about lab results...I thought that we were not allowed to code from a lab report?
 
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We can't code from diagnostic or lab reports that are separate documents from the Office visit but we can use the lab report results if it is incorporated in the Progress Note/Office visit as TAMPER. To clarify, you cannot take the lab report results and see a1c that is high and automatically assign that the patient has Diabetes without the diagnosis of Diabetes being discussed in the note; but if there is Diabetes notated in the hpi, pmh, or a/p section, then that is your TAMPER/MEAT to make the Diabetes current/active. Of course, working for different clients, they may have different guidelines and may not accept lab results as TAMPER, and some may only accept it if the lab results are within a 6 month or within the same year timeframe of the Date of Service rendered.
 
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