Wiki Dx code throughout note

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Tonyj

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I believe this subject was previously discussed but I need a refresher. When coding charts I had used what may have been mentioned in the HPI as supporting diagnoses. Example: Pt presents for f/u to CML. Pt has multiple co-morbidities inclusive of HTN, diabetes, heart disease, kidney disease....

The A/P may mention only treatment regarding (chronic myeloid leukemia).

In the past I would include in the diagnoses the multiple co-morbidities mentioned in the HPI as well as the CML. Now, I've been told I could only use what the MD mentions in the A/P no matter whatever else was mentioned in the body of the report. Past forums responded as it is ok to use past surgical and medical history when coding diagnoses.

Am I wrong to include those diagnoses if they are not mentioned in the A/P? Or can I continue to use diagnoses found throughout the body of the report? Any assistance with corresponding documentation would be greatly appreciated.
 
The general rule of thumb is if the condition is a known co-morbid condition then you code it, if it is managed controlled or treated then you code it. If none of this applies then just because the condition is in the history does not mean you code it.
 
When in doubt...

I always go back to the ICD-9 Coding Guidelines. In this case, I referred to the outpatient guidelines and found this that may help you:

K. Code all documented conditions that coexist

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
 
Question in regards to this...I'm well aware of the Item K...code all conditions that coexist; however, don't these conditions need to have some indication they've also been addressed?

For instance, patient seen for multiple myeloma also has CKD mention in past history. Doesn't the physician need to indicate something about the CKD further than just listing it in past history for us to code this condition?

Such as advised patient not to use NSAIDs due to CKD. Or due to patient's CKD, we will be limiting the use of...etc.

In several seminars I've attended, this point comes up and the acronym "MEAT" is used. That is we have to see the condition was somehow monitored, evaluated, assessed or treated. And can't just be listed on a past medical history or problem list.

Just want a little further clarification...thanks!!!
 
you are correct, the phrase "code all conditions that coexist" is a little misleading. A problem listed under past history is exactly that history. If it is not relevant to the current condition then it will not be addressed by the provider in the exam. If he pulls it forward to the exam then he deems this condition to be relevant to why the patient is here today, if the ROS indicates a chronic condition as being abnormal but then does not address it in the exam, I would query the provider. I am sure we have all observed this in the past where a condition in the ROS is a concern but then in the exam is a non issue or normal.
But back to your question , if it is not relevant to the provider how can it be relevant to the coder?
 
Carrying this one step further...

I have seen chronic conditions that are listed in the ROS, not addressed in the exam, but then mentioned and/or addressed in the treatment plan. This is especially true for things like HTN, hyperlipidemia, etc when the physician will make adjustments to medications. Of course, this would be a no brainer to include the dx code, but you are right Debra - the physician should be queried if there is any doubt.
 
You are correct, the phrase 'code all conditions that coexisist' is taken out of context.
The ICD-9 diagosis coding guidelines indicate that (generally speaking because we all know exceptions to the rules can be the name of the game in coding) only substantiated codes should be coded and submitted.
 
How do you handle situations where the pt no longer has the comorbidity due to weight loss, for example? I have asked our drs, and have gotten conflicting answers. Hyperlipidemia is the main one I have run across.. once a person is diagnosed, do they carry that dx with them forever? If not, then does the labwork revert to screening after a certain length of time of normal lab values? Or is this up to the provider to decide? Any input is very much appreciated!
 
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