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LindaEV

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Do you count co-existing conditions, that are not treated, but are listed in the dx list?
Pt sees a general surgeon for hemorrhoids, exam is problem focused...but surgeon lists all this guys co-existing problems in his assessment list. Do you count these in the "amount of diagnoses" box, or in the table of risk?

What if they are related or not related....like this guy has asthma, diabetes, depression, sleep apnea, and Hx of Colon cancer.

Can you take this into consideration for say a minor surgery with risk...or does the doctor have to state specifically that because of his chronic illnesses there is more risk with surgery?

Thanks
 
Good question. I had a discussion with an outside auditor about this very issue. She said that if the other problems were not addressed other than to list them (ie problem list, past med hx, etc) she would not count them. If, on the other hand, they were documented in the assessment and plan and it was clear they were contributing to the medical decision making process, she would count them. I agreed.
 
No problem points

I wouldn't count these "diagnoses" in my problem points - nor would I code them.

But I would consider them as co-morbidities for determining risk.

F Tessa Bartels, CPC, CEMC
 
problem list for risk adjustment

If you have the problem list of co-existing, and are coding risk adjustment, would you use this list of "problems" if you also have a list of current medications to support each dx? This is a sensitive subject in our department mainly because some coders do not think you can code from a "problem" list period. I see that some physcians using EHR use the term "problem" or "PMH" or "active problems" etc. Does it matter what subtitle the Dr. puts above the patients history?
 
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