Question Coding from history and med list

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I am trying to code an encounter for a patient who came in for pre-op clearance. The provider did not fill out our progress note, he wrote "see H&P which is a separate form from the surgery center itself that he filled out. He documented a few conditions with a plan such as stable or controlled. When I received the encounter, he also circled some codes that were on the H&P as personal medical history. He did document meds as well but did not link them to the specific conditions. So I guess my question would be can I code from the history without having a plan specifically linked to the condition? I know what medications go with certain conditions, but not being clinical, am I allowed to do that? Any help would be greatly appreciated!
 

Orthocoderpgu

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I have a question. Has the decision for surgery already been made? Keep in mind that after the decision for surgery, evaluating the patient before surgery is included in the surgical package. It sounds like you could be billing for pre-op visits which could lead to significant fines.
 
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Yes, they are already scheduled to have the surgery but we are their PCP, not the specialist. The specialist needed him cleared due to his chronic health conditions. Also, this may not matter but I will mention that he has a medicare advantage plan.
 

csperoni

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The pre-op clearance by someone other than the surgeon (or surgeon's group) is absolutely billable.
You would typically code E/M 99201-99215. For carriers that still permit consult codes (very few do anymore), 99241-99245 are acceptable.
First dx: Z01.818 preprocedural exam
Second dx: reason for the surgery
Any additional dx as appropriate. This can be whether it's in your EMR progress note or the form.
https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/coding_preop_exams.html
Hope that helps.
 
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I appreciate the input but I think what is confusing to me is the fact that the provider documented some conditions under PMH such as BPH, Essential tremor, Depression, etc but did not document a specific plan for any of them. He did document medications on the form but did not link to any conditions. As a coder, am I allowed to code those conditions if I know the medication would be for that condition? I am not clinical. I hope this makes sense...
 

csperoni

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For office/outpatient coding, I only assign codes that have HPI, treatment plan and/or documented to affect the treating problem. I know risk adjustment coding allows for more chronic conditions, etc to be coded, but I am definitely not well versed in that world.
If you are part of a healthcare system, I would go by their policy. If you are private practice, I would only code what the physician documented as treating or affecting care.

I know with EMRs, a lot of information gets pulled from history & meds. If this med list is just what the patient was already taking, or history pulled from prior (or even other physicians), I would not code those diagnoses. In your example, if the patient has BPH and on medication/treated by urologist, I certainly would not use that diagnosis unless it is the reason the surgery. Some EMRs forces the clinician to pick the reason for the prescription.

If this is a recurring issue and you believe the diagnoses were evaluated, but not documented, I would suggest educating the provider about linking information. Coders are not supposed to be physicians (and the reverse).

Hope that helps.
 
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