JLRees
New
I'm currently coding hospital E/M encounters and was looking for some clarification on assigning DX codes. When the physicians document in the assessment ALL of the medical DX that the patient has, including diagnoses that are not actually being treated, do you assign those DX because they are listed by the physician (and can complicate the patients treatment) or do you only assign the DX that are actively being "treated". For example, a patient who is admitted with sepsis, metabolic encephalopathy and acute renal injury, all of which are being actively monitored and treated. The doctor also lists dermatitis, obstructive sleep apnea and chronic low back pain in the assessment, however, none of these things are mentioned in the treatment plan as being treated, medicated or monitored.
So, do you assign these DX to the encounter because they are documented in the assessment by the physician? Or do you leave them off because there is no documentation of them being treated, therefore shouldn’t be considered in the MDM? Both make sense to me. On one hand, if the physician doesn’t document that he’s treating a specific illness then you can’t assume that it actually complicated or affected the overall MDM. But on the on the other hand, if the physician documents an illness/DX in the assessment, it’s reasonable to think that it is taken into consideration during the overall MDM, even if it’s not actively being “treated”. So which is the correct way to assign DX, per coding guidelines. I’ve looked but am unable to find anything that specifically addresses this. Any guidance on this scenario would be much appreciated.
So, do you assign these DX to the encounter because they are documented in the assessment by the physician? Or do you leave them off because there is no documentation of them being treated, therefore shouldn’t be considered in the MDM? Both make sense to me. On one hand, if the physician doesn’t document that he’s treating a specific illness then you can’t assume that it actually complicated or affected the overall MDM. But on the on the other hand, if the physician documents an illness/DX in the assessment, it’s reasonable to think that it is taken into consideration during the overall MDM, even if it’s not actively being “treated”. So which is the correct way to assign DX, per coding guidelines. I’ve looked but am unable to find anything that specifically addresses this. Any guidance on this scenario would be much appreciated.