Wiki Hypertensive Heart Disease

[heartyoga]

I attended a seminar that the speaker states that there are some heart conditions that "never go away" and should be coded and be in the assessments in every visit, e.g. Hypertensive Heart Disease, Chronic Kidney Disease, Heart Failure, etc.

She told us we "could get in trouble" if we don't do this.

I just want to verify if this is something valid and if this something I need to speak to our busy physician about. Reminding him to put it in every encounter, even though clinically it is not the main problem for the visit?

Thanks.

 

[thomas7331]

I have never heard something to this effect and it is hard to understand what this speaker may have meant without the context of the talk. There are indeed health conditions that do not 'go away', but it is not within the scope of coding to know what those are, and certainly not a coder's normal responsibility to instruct a physician in what they do or do not need to document as relevant to their patient encounters. Unless and until you have something in writing from a payer (such as a requirement to document comorbidities that is part of a risk/shared savings program) or a regulation or document that you can cite as a reference to back this up and give more detail, I would not trouble your physician with something like this.

 

[heartyoga]

Thanks

Thanks.

The speaker is an auditor and she may be speaking based on her experience. I may have taken it out of context.

It is a relief to not have to bother our busy physician.