Wiki E/M MDM Question on chronic conditions unrelated to CC


San Juan Capistrano, California
Best answers
Hello, we are a family planning specialty so most of our patients are seen for STI / Infection checks with symptoms such as discharge, painful urination, lesions, etc... If provider included chronic conditions such as elevated BP, hypertension, obesity that are not related to the chief complaint do I count these in my problems addressed when coding for office visits?

Example documentation:

CC: STI check

Encounter for initial prescription of other contraceptives
Encounter for screening for human immunodeficiency virus [HIV]
Encounter for screening for infections with predominantly sexual mode of transmission
Encounter for screening for other infectious and parasitic diseases
STI partner exposure (chlamydia, gonorrhea, syphilis or trichomoniasis)
Elevated BP without diagnosis of hypertension
Clinical Notes on elevated BP: Pt states he had pre workout 2 hours ago and came to the clinic straight from the gym. Advised pt he must monitor BP at home and to f/u with PCP asap if remains elevated. Reviewed strict ER precautions; pt verbalized understanding with intent to comply.

Thank you so much for all the help!
You code diagnoses that are being addressed/treated or affect the treatment the provider is planning for another problem.

In your example above, while it's not what the patient came in for, the provider clearly documents that they addressed/treated elevated BP. I would put R03.0 on there and count as an ACUTE problem here. Chronic means expected to last > 1 year or the life of the patient. That would typically be for hypertension, but this patient is NOT diagnosed with hypertension.

In general, if the provider is simply listing the problems, but do not seem to be addressed/treated or affect the treatment, I would remind the provider *IF* they affect the treatment, they must link it for you. For example, if they would typically treat with prescription 1, but instead need to treat with prescription 2 and order labwork because of diabetes, then the diabetes is affecting the treatment plan. A common example might be - provider would typically prescribe steroids at a certain dose, but due to steroids impacting glucose control, might order at a lesser dose, or instruct the patient to monitor their blood sugars more carefully. Or a female patient on OCP with hypertension - provider might instruct to discontinue OCP due to the hypertension.
Hi PPaule:)
If the provider list the chronic conditions as 2nd dx I d add them in his or her s list of assessments. Some providers list a lot of unnecessary dx whereas some just list the most important 4 dx (most payers say they do not look past 4 dx codes in outpatient setting). If it is all documented and describe their condition then list dx assessments. The provider should know which disease (ie N18 or E11 ) may affect the current STD disease thus why provider listed. Let us say the patient is being treated or STI and has past history of this I d put the Z dx code down (last) if listed in the past medical history of that days treatment record. Hopefully the provider is listing the OB/GYN or geniurinary problem for males if the patient has a ds. or symptoms using Z code as first dx will not always get the best payment back. Documentation to support medical necessity & description is vital ,not just encounter of Z dx code. At times Z dx can be used and Ev Mgt code but does depend on provider s documentation. Also if can look at lab results you can code this if positive STD results. Such as patient gets positive lab results such as B00.9 Herpes A54.0 Gonorrhea, A59.9 Trich and then use dx Z11.3 as 2nd code. Patient has infection or irritation in private bits area then can use dx N34.2, N48, N77 and Pelvic Pain R10.2 then dx Z11.3. This is jsut an example. But the provider must document this in record and list it in assessments. However if only doing lab test blood or pap add this Z01.419, Z12.72 or Z12.4 but some type of dx R symptom code or N70-N72, N76 or N77 or N92-N94 dx code may help if documented.
Well hope I helped you.;)
Lady T
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