Question Number of Diagnosis and/or Treatment Options

LOUISE SLACK

Networker
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45
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0
When quantifying the number of diagnosis in Chart A of MDM on the audit tool I am unable to find guidance as to how to combine or count separate each diagnosis.

For example a patient with liver disease lets say alcoholic cirrhosis. The list of diagnosis in the note will include ascites, portal hypertension, splenomegaly, thrombocytopenia etc.

All of the listed conditions can and probably are a disease related to the cirrhosis. When quantifying the chronic stable and/or unstable # of diagnosis do we count only one for the cirrhosis. Or can we count all diseases listed (5)even if related to another diagnosis.

Another example a patient with tremors and a Parkinsons. Is that two chronic stable points or 1?

Is there an authoritative publication that can tell us how to count diagnoses when they are related?

Thank you,
Louise
 

Pathos

True Blue
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638
Location
Beaverton OR
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I would be very cautious to include a symptom of an already managed condition. I believe our coding guidelines state to not code/use symptoms if a condition of the symptoms is identified and managed. I would probably also not include conditions the provider is not addressing and/or managing in the note. If he/she is merely listing them and not addressing the condition, then I would not consider that condition towards any score.

So in your examples I would do the following:

  1. This really depends on the note. Is the provider addressing the Ascites, Portal Hypertension, Splenomegaly, Thrombocytopenia, or just listing them blankly, or is the provider dealing with each condition separately. If the case is the first one, then I probably wouldn't use any of those conditions (except for maybe cirrhosis).
  2. I would probably only code Parkinson's, as Tremors is a direct symptom of Parkinson's disease.
Again, each statement is dependent on provider documentation.


Hope this is helpful!
 
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