Wiki Family History Codes

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KaylaRieken

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Do family history ICD 10 codes count towards your diagnoses points in medical decision making? I work at a Urology office and we are seeing a patient for microscopic hematuria. Patient also has a family history of prostate cancer and so they decided to run a psa. Does the family history of prostate cancer count as 1 point new/stable for diagnoses?
 
I have this same question again. My doctor listed these diagnoses: 1. BPH with Luts 2. Elevated PSA 3. Family history of prostate cancer; My question is would this be just 2 stable diagnoses? He is counting it as 3 stable diagnosese, but I disagree with that.
 
The audit tools that assign 'points' for diagnosis don't give a lot of guidance on this type of question. However, if you look at the tools and the guidelines, the 'number of diagnoses' portion of the MDM is based primarily on how many problems the provider is evaluating and treating, not on the number of diagnosis codes assigned. In my opinion, a family history of a disease could complicate a problem, but it is not a problem in itself (if anything, it could be a factor in the risk section) but it can't be considered stable or worsening, and can't be treated. In addition, I would not usually count symptoms as problems separate from the diagnosis with which they are associated, unless documentation supports that the provider is looking at them as a potentially different problem. I would look at and count what problems that provider is actually addressing and treating at the visit. And I usually do this in the context of the provider's documentation of the assessment and plan, not just off of a list of diagnoses.
 
I agree with Thomas on this one. When determining the MDM, you need to look at the whole documentation in its full context, and not just in the A/P as not all charts are created equal. Additionally, if you are using a point system to determine the MDM, then be careful not to over inflate the points by counting everything. As a coder, it's your job to be very critical in determining what is usable, and what is not. A History diagnosis (Personal or Family) is usually not eligible for MDM because while a History code does provide useful information for the doctor and the overall prognosis of the patient, you cannot determine if the History code is New, Established, Stable or Worsening.

I would recommend not using a Personal History or Family History code towards the Diagnosis/Management Options part of the MDM, because it does not show how the provider is treating and managing the patient's health. A History code is also not a condition, but more of a statement.
 
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