History of diagnosis coding

cgifford

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Mechanicsville, VA
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Patient comes in for lets say a rash, the patient is treated and the doctor bills the diagnosis rash with the E&M service. The patient does have a history of MM, can we also bill the DX Z85.820 for his history along with the rash dx? Even though he was not "treated" for the History Of DX, It was noted the patient has a History of in the progress note. Please advise and if you know where I could find any documentation in black and white regarding this topic please share. thanks so much!!1
 

Chelle-Lynn

True Blue
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Modesto, CA
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You would only list the additional diagnosis if the physician is managing care or providing an evaluation for that condition during that visit. The care of the condition would need to be listed as part of the assessment of the patients condition and the documentation would need to support the use of the code with the medical decision making process.

Generally if a patient has an on-going diagnosis it is listed in the history section of the documentation as part of the PSFH if it is not being evaluated, managed, or treated during that days service.

Example:

Patient comes in for treatment of an ear infection
The patient has a history of diabetes
The diabetes is not evaluated or treated during the visit as the exam was problem focused to the ear infection

In this case the diabetes would be noted as part of the patients PSFH but would not be included in the MDM on the date of service.
 
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