E/M coding help - establishing care and med

samyjm13

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Meridian, ID
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I know that if it is not documented it didn't happen. But,,, a new patient comes in for establishing care and med. refills, provider addresses the reflux, allergies and prostate cancer in the note, addresses nothing else. Now in the Assessment the provider puts the following DX : Hyperlipidemia, depressive disorder, arthropathy, gall baldder colic. and of course the addressed DX. However, these DX I have mentioned that have not been addressed in the note, are in the PMH. My question is can I code them? We are having a bit of a difference of opinion here in our office. Can someone help with the our discussion?

Thanks, Jeanne
 
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Bradenton, Florida
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I would only code what was pertinent specifically in this visit based on presenting illness, meds prescribed, and current complaints. it is important not to code things that are "history' of unless you are in fact using a history of ICD-9 code.

A patient may have had gallbladder colic two years ago but if it is not a current acute issue or chonic issue your provider is treating then it should simply remain in the history portion of the documentation, there would be no need to code it on the claim for the current date of service.

In terms of patient history, caution must be used as you can inadvertantly "give" a patient a disease or illness they no longer suffer from. This can affect a patient if they for example; apply for life insurance.

Good Luck!
 

maine4me

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Can I take this question a step further? If the states in the assessment how they are treating the conditions which were addressed and then goes on to say no changes to other meds, should the diagnoses for all the meds be coded?
Also, if a condition is addressed, but is being followed by another doctor, (for example, patient has afib which is followed by the cardiologist) do you code the diagnosis?

My scenario is also for a patient who is a new patient, establishing care.
 
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