outpatient guidelines for pmh

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Murfreesboro, TN
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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.
 

thomas7331

True Blue
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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.
 
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