Documentation required for coding chronic conditions

CPCA2016

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I am in need of clarification of the required documentation to code chronic conditions. If the CC states "F/U" and states "depression symptoms controlled, blood sugars low, HTN" and the plan states "continue on current meds, follow up in 1 month or prn" and includes lab results, can you code depression, DM, and HTN?

I am definitely thinking no, that each condition needs to be assessed and treated in order to code them. Such as "HTN controlled" or "HTN controlled on current medication" and likewise for the DM and depression. I know a coder can not interpret lab results. And as far as the plan goes; should it say something like "continue Metformin for DM" not just "continue current meds"?

I am looking for specific information of what needs to be documented in order to code all the chronic conditions.

I thank you in advance for all information!
 
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Is there more to the documentation other than "depression symptoms controlled, blood sugars low, HTN" or is that the whole narrative? Obviously it's inferred, but does it state a DX of DM?

If you're using the 1997 guidelines, the status of each MUST be included in order to count three chronic conditions, but the 1995 guidelines don't make it mandatory. However, for both the 1995 and 1997 guidelines, "F/U" is insufficient to consider it as a chief complaint. There has to be extension as to what it is exactly that's being followed up on. It can be indicated in other areas of the documentation, but based on what you've posted, it's nowhere. One might assume it's a follow up regarding the conditions, but as they say, "if it's not documented.." Long story, short, without an actual CC, the visit would be considered not medically necessary.

https://www.aapc.com/blog/23875-8-tips-for-compliant-history-component-documentation/
 

CPCA2016

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Sometimes this particular providers notes just say "follow up" and then below it the conditions are listed. Sometimes it is more specific. If it states "continue on current meds" in the plan is that considered enough to document the chronic conditions if they are listed in the assessment? Thank you for your input.
 

Chelle-Lynn

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If this is in regards to the coding the "number of chronic conditions" under the history of present illness, then additional information is needed. The history from the patient in regards to their impression of the current status is needed in order to allow for this criteria;

Example:
HTN - Patient states HTN is controlled with meds
DM - Patient indicates that BS has been 120 after meals
Depression - Seems better with medication
Obesity - Patient noted gained 10 lbs this past month

The status from the patient of the chronic conditions needs to be noted. It should not be gleaned from the physician's assessment of the condition, the status needs to be from the patient.
 

jsturgeon

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I recently received an audit with the auditor stating if it in is the PMH section then I should code the chronic conditions. I disagreed and was informed that if it's in the chart I should code. My point was the provider only mentioned the chronic conditions in the past medical hx and the medication was mentioned in the medication section, nothing current documented to indicate he was reviewing the medication given and nothing in the plan/assessment indicating the patient was being treated that day, any advise?
 
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