akandrew
Networker
I work for a vendor who does Medicare risk adjustment. The coders were informed recently by the director of the company that we are to start coding from PMH and the medications list. For example: if we see chronic conditions listed in the PMH and we can identify that they taking medication from the medication list, we can code that condition. I have never been trained to code that way and I am having a hard time complying with the company's wishes. I am trying to find some documentation pertaining to this type of coding to show one way or the other that it is or is not proper documentation coding. I believe that the medical record should have specific language from the provider that the patient is being treated for a chronic condition such as saying: "patient has a history of a-fib treated with coumadin" instead of seeing a-fib in the PMH and coumadin in the medication list and matching them up. We are told to code this way if the patient is being seen for a completely different condition. I need some feedback on this or some direction to documentation guidelines. I explained to her that we are not nurses and I am uncomfortable coding this way. I have reveiwed the ICD-9CM Official Guidelines for Coding and Reporting several times to see if there was any reference to medication lists and PMH. The only item I found close to my dilemma is in the Outpatient Guidelines, K. (Code all documentated conditions that coexist).