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Wiki E&M question on diagnosis

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boceanmist

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For a hospital Initial or subsequent visit , If a diagnosis is listed in the assessment and plan as history of .. but no additional detail of how it was assessed should it be listed on the claim? Ie: patient presents with a hx of cad, hypertension, diabetes presents with acute cholecystitis. the comorbidities would be considered when planning the surgery but not necessarily. treated by the provider planning the surgery. should they be listed on the claim?
 
The first thing I would do is try to get the providers to stop using "history of" to mean "chronic condition." :) The patient still has those conditions, they're just controlled. History of means something different to us (condition is no longer present, not undergoing active treatment or monitoring.)

If no treatment is directed at the CAD, htn, etc. during the course of the hospital episode, no, they do not go on the claim.
 
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