Medication List / Risk Adjustment

rmooney1114

Networker
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44
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Monson, MA
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Hello, I have a question in regards to using a medication list in order to validate diagnoses reported within the record. If a patient has for example COPD in the PMH/PL list and it is not validated anywhere else in the note, but in the current med list, the medication Ventolin is documented, would you accept that as validation in order to report the COPD from the PMH/PL list? We have had several debates on this, and my issue is that unless its specifically linked that the Ventolin is being updates/renewed/reviewed for COPD condition, then we cannot assume and accept the COPD from the PMH list. I have the AMA Risk Adjustment book, it also states that we cannot code from the med list and that there should be a linkage between the medication and that condition.... Also a lot of medications have more than 1 indication, so if its not specifically linked for that condition, how can we assume that a medication is for that specific condition. I have been having a constant debate on a risk adjustment project in regards to this, so I am curious to what other coders think and if you have any specific references to back anything up I would appreciate that.

Thank You
 

TThivierge

Guru
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144
Location
Lithonia, GA
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Med List = Dx Coding= Not a good idea

Hello

No I would not select a diagnostic code from a medication list. The physician needs to tell you the health problem with some kind of dx description.


I hope this info helps

Lady T
 

bburdett

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I think it depends on your company's internal rules, if they cover it. Where I work, we would pick that up. COPD is a chronic condition that, once the patient has it, never truly resolves and is always relevant to the patient's medical care. CMS and coding guidelines allow for such conditions to be coded, even from patient history, when there's nothing documented to contradict it (like, say, a history of lung transplant).

In addition, the med list can always be considered an indication of active care as the provider (presumably) reviews and validates each medication at each encounter where it is included in the documentation. When a provider prescribes or validates a medication that is commonly used as a treatment for a chronic condition such as COPD, and the condition has been documented on the note, the provider (again presumably) is at least considering how that condition is affected by the medication, even if that's not the main reason it was prescribed.

Remember, the ICD guideline for outpatients encounters is "Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care, treatment or management." With a condition like COPD, it affects MDM for anything the provider does related to breathing.

Of course, some coders and companies are much more conservative about their interpretation and documentation requirements.
 

Delta2016

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ROYAL PALM BEACH, FL
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Yes, I would capture the J44.9 because the medication is a form of treatment unless you have another condition with the same treatment (Ventolin) then the provider has to be specific what condition is the one being treated with this medication?
 
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