coding chronic condition icd10 from problem list

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Scenario: Patient comes in for a visit with his FP doc to discuss his chronic cough. The MD just notes the discussion of the cough but the patient has diabetes, HTN, etc in his problem list and he refills his HTN meds and DM meds that day both of which are documented in his note for that day. Can HTN and DM be coded for that days visits along with dx for cough?
 

thomas7331

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Per the ICD-10 guidelines: Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Refilling medication, in my opinion, would qualify as patient care management at the encounter, as long as the documentation reflects this.
 

momo2

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Hello,

As a Risk Adjustment Coder, I have thought about this scenario also and agree with the previous reply ONLY if the DM and HTN did not factor into the E/M level selected UNLESS if the provide prescribed a medication for the cough that affected the DM/HTN or vise versa......
 
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