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Past Medical History Coding

L

lvaughn0624

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Omaha, NE
I am reaching out to the community to get a consensus on coding from "Past Medical History". I have some pushback from my current employer that specializes in LTC/SNF for the county I live in. They believe that if PTSD is on the patient's past medical history than it should be coded and added to their Diagnosis List; however, there is no supporting documentation from a medical provider showing that they have addressed or confirmed that diagnosis. I do not believe we should code this due to not actively treating the PTSD at all and not having documentation supporting it besides it being listed in their "Past Medical History". Can I get thoughts or guidance on this? Thank you.
 
PTSD, while not being actively treated, is not a condition that resolves itself. I can understand the perspective of 'if PTSD is in the PMH then code it', and I've worked for a provider that had us do it that way.
On the other hand, I'm current working with a hospital system that has me ignoring everything in the PMH unless it is something being actively treated on the day of service.
If you have a coding coach at your office, ask them. But I'm guessing you do not, which is why you came here.
Sorry that I do not have an answer to your question but wanted to validate for you that it IS confusing. I hope you get the answer you need so you're not second guessing yourself at work.
 
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