ER T sheets and Hx codes

Kerri

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I am looking for feedback on the Hx codes on a T sheet from the ER docs.... I will code the Hx Dx ( personal and family), however if there is not a HX code for that specific Dx do you just not code it or do you give it a current code?
 

Mojo

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We code chronic conditions and history codes if they are relevant to the encounter (treated, addressed or aid in MDM). We assign a dx in the PMH as a current code if the condition continues to be treated and affects the management of the presenting problem.
 

mitchellde

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If it is a problem that is no longer being treated, and is history of, then you do not code it . Do not use a current code for a past issue.
 

Lizz B

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Hey, all, appreciate the input! I'm new to ER coding and finding LOTS of questions! Regarding the above info, had similar scenario. Under PFSH, DM is listed for patient, and indeed, patient med list has Glucophage listed. Patient came to ER after glucose meter gave reading of 320. Final Impression by ED doc is hyperglycemia. Patient was given IV fluids. It seems to me that if the patient is taking DM meds and uses a glucose meter, that I should code DM as the principal dx. However, as noted, the ED doc never mentions DM anywhere. Suggestions? Thanks for any ideas.
 
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