Wiki Chronic Condition Coding in the ED

[Tamara314]

Does anyone have any experience with ED departments coding chronic conditions (both HCCs and non-HCC diagnoses) based on the provider pulling in the "Patient Medical History" into their note?

My concern is that I don't see the diagnoses being supported by any MEAT documentation. I also see them coding items as active even though the provider note says "history of".

I am having trouble finding documentation in the coding guidelines to support my teaching of it has to MEAT the diagnosis and "history of" infers that a diagnosis is in the past (resolved).

Thank you in advance for your guidance!
Tamara

 

[TThivierge]

Hi Tamara
Here is my take.... add past medical history if related to current problem being seen for today. Add chronic condition if doc list them in assessment, but some med centers policy is add chronic conditions lastly on claim if listed in current med history section or doc mentions it. List chronic conditions such as HTN, DM, CHF,CHKD, CA, HIV, COPD, if on the patient's record. I do see some doctors list a current illness under dx codes but as I read the med record, he or she, the doctor, will say this illness happened 2 or 3 years ago. I do not add it UNLESS related to current illness. Some things always should add if listed in patient's medical record & make sense per doctor's note ....if pt. suffers with arm, leg, feet amputations, heart pacemaker, cardiac implant or graft see dx block Z95, organ transplant= check dx block Z94, takes insulin Z79.4 for DM, smoking current dx Z72 or F17 or past smoking history dx Z87.891 if patent has heart or respiratory or hypertension chronic conditions. Also hopefully your ER physicians list down types and levels of illnesses in diagnosis of CHKD, HTN, Pressure Ulcers, Skin Burns, Diarrhea, kinds of drug addictions, Asthma, Sinusitis, Alzheimer, MI, Depression and types of fractures....just to name a few. What bugs me is doctor missing skin conditions on telling me where at on patient's body and not telling the laterality of extremities, ears, kidneys, thyroid, or eyes. Yikes!!

Also if pt. has an trauma injury (IE: fall downstairs, car accident, bit by animal, hit by person) add place, how it happened and date of injury too. Then you can add some chronic conditions if warranted per the notation and current illnesses. Hey hopefully your ER template med record has places for past med history, list of meds, the ROS, and current problems so doc can help you do medical abstraction coding with clear documentation because every patient has a story.
Well I hope this helps you!
Lady T

 

[chantal777]

Hi Tamara
Here is my take.... add past medical history if related to current problem being seen for today. Add chronic condition if doc list them in assessment, but some med centers policy is add chronic conditions lastly on claim if listed in current med history section or doc mentions it. List chronic conditions such as HTN, DM, CHF,CHKD, CA, HIV, COPD, if on the patient's record. I do see some doctors list a current illness under dx codes but as I read the med record, he or she, the doctor, will say this illness happened 2 or 3 years ago. I do not add it UNLESS related to current illness. Some things always should add if listed in patient's medical record & make sense per doctor's note ....if pt. suffers with arm, leg, feet amputations, heart pacemaker, cardiac implant or graft see dx block Z95, organ transplant= check dx block Z94, takes insulin Z79.4 for DM, smoking current dx Z72 or F17 or past smoking history dx Z87.891 if patent has heart or respiratory or hypertension chronic conditions. Also hopefully your ER physicians list down types and levels of illnesses in diagnosis of CHKD, HTN, Pressure Ulcers, Skin Burns, Diarrhea, kinds of drug addictions, Asthma, Sinusitis, Alzheimer, MI, Depression and types of fractures....just to name a few. What bugs me is doctor missing skin conditions on telling me where at on patient's body and not telling the laterality of extremities, ears, kidneys, thyroid, or eyes. Yikes!!

Also if pt. has an trauma injury (IE: fall downstairs, car accident, bit by animal, hit by person) add place, how it happened and date of injury too. Then you can add some chronic conditions if warranted per the notation and current illnesses. Hey hopefully your ER template med record has places for past med history, list of meds, the ROS, and current problems so doc can help you do medical abstraction coding with clear documentation because every patient has a story.
Well I hope this helps you!
Lady T

Hi All,

I agree with Tamara takes on the matter however, I must add that ED physicians only care for the reason why patient is in the ED. often time they don't care too much about other diagnoses patient might have. I would look at the medication list and code chronic conditions based of that. Also keep in mind that the list might not be up to date, in some cases patient might not be taking meds for a couple of reasons. that is why we coders, we rely on the provider's documentation but we all know how it is.

Good luck.
Chantal

 

[Pathos]

In order to pick up HCC conditions, we need documentation to validate any HCC codes as active conditions. While we have the mostly clear-cut guidelines on how to pick up certain conditions, we have plenty of areas where things get a little more problematic.
As @TThivierge mentions, we have the 9 chronic conditions (COPD, HIV, CHF, DM, RA, Afib, etc) which most of the time can be used, although you still need to be careful. Even these chronic conditions can be negated depending on documentation. Did the Afib have an ablation? Was the Afib a product of a procedure and an one-time thing? Is there a note in the chart that conflicts with the COPD?

When it comes to Past History and Problem Lists, we as coders know that these two areas are generally not a place we can just go wild and snag uninhibited from. Most EHRs park old conditions in either areas and often do not clean them up afterwards. It's like leaving a bunch of dishes in the proverbial sink, and just letting them sit there for a very...long...time. In general I would be very cautious in validating HCC conditions or even non-HCC conditions from a Past Medical and/or Problem List, as they usually are not documented as active conditions. However, there can be exceptions. I have seen charts where the PMH/PL is essentially an extension of the HPI or A/P, because they have included additional updated information to pull that condition out of the History and into the Active status.

As for providers using "History of", we again need to look to the documentation. I have seen countless of charts where providers use "History of" for a condition that's just stable, but still active. When we as coders see "History of", we usually think the condition has resolved; not always so when it comes to provider documentation. My advice here is look to the chart again. Are there any Monitoring happening? Evaluations? Assessments? Treatment of any kind? If you can honestly say yes to either of these four questions, then you probably have your validation right there. There are always exceptions, but remember that every chart is different (unless it's a true cloning), and can change your assumed direction for validation.

Hope this helps! If not or if you have questions; ask!