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Wiki Comorbidity DX

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torih@nwurology.com

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Beaverton, OR
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Hi group,

I'm trying to settle some confusion. When patients fill out a history form, they will list their medical problems, ie. hypertension, DM, CAD, etc. My provider will assign those dx codes to their visit note but NOT mention anything about the status of the diseases or even mention the patient has it (we are a urology office and wouldn't be managing these problems anyway). I do not think those codes should go on the claim as a supportive dx if the provider doesn't even mention that the disease is stable or unstable. Am I thinking correctly?

Thanks
Tori
 
I agree with you. The rule is we code it if it is documented by the provider as being managed, controlled, or treated, or documented as a complicating issue.
 
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