Wiki Medical history

[sparkles1077]

When the provider has a list of chronic illnesses under medical history, but does not mention them in the rest of the note, do you code them? Example: Hypertension and end stage liver disease under past medical history. Do you code these?

Thank you,
Sparkles

 

[Wendyh50]

Use them in your E&M

If you need them to code a diagnosis ask your provider or supervisor what the company policy is, then put one in place so that they will or will not be used by future coders.

 

[johnmeyer]

That would depend on if the chronic illnesses are related to the reason for the visit.

For example…

I work in an orthopedic clinic. To use your example, if I was coding for a patient with hypertension and end stage liver disease, I wouldn’t code either if the patient was to come in complaining of knee or hip pain because what does his/her hypertension and end stage liver disease have to do with knee/hip pain?

Now let’s say I’m coding for a patient who is coming to see our pain management specialist who has a history of drug dependence. I would code the drug dependence because this might be related to the office visit since our pain management specialist can sometimes use some pretty powerful drugs to manage a patient’s pain.