If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
I need clarification. If a condition is listed in past medical history, hld for example, and a med is listed that treats this condition, should it be captured as current.
Please advise.
The ICD-10 guidelines for outpatient coding say to 'code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.' So I would not code a diagnosis from the history or medication list unless the provider has documented that that condition was treated or was a factor in the care that was given at that particular encounter. I'd also note that it's outside the scope of coder training to make a determination as to what condition a medication is prescribed for if that information is not specified in the notes.