Wiki Question on Medical Record Documentation

TThivierge

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Hello,
I have some questions related to documentation by provider when abstracting or auditing the current medical documentation.

1. If the patient is dealing with a ongoing illness(chronic condition) but treated by another medical specialist doctor should the current physician list it under the dx assessment? Do you add the dx code if current or code it?

2.If a patient has Cancer, older than 5 years and it is gone, you would add to patient history using dx blocks of Z85 especially if pertaining to current illness. I know providers are to list years or when cured for past illnesses. But if pt is getting chemotherapy or cancer meds do you count the cancer on the list of current dx if physician forgets ? Or query him or her ?

3.If a provider adds an addendum after 3 days from original date treated: can you add it onto the dx assessment of a current illness?

4. The patient gives the NOC or Chief complaint plus it is listed in the Review of System section and the symptom or abnormality is noticed by the provider. However he or she FORGETs to put it in the current list of dx and assessments? Would you add the dx or symptoms from the provider s note under ROS plus addressed in his HPI section or query the doc for more data?
Thanking you in advance
Lady T
 
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Current E/M may focus on the "reason / complaint" and "treatment / plan of care" for the current episode and visit. PT may have history of CA or other treatments. I would query Provider if "History of" pertains to current episode of care. History of may certainly affect more complex medical decision making, medications and interactions, labs, and or other diagnostic tests and procedures. If visit is for common cold, CA + chemo History may not be applicable unless the assessment or treatment plan state as such.
Good Example, specialist is treating for back pain with steroid injections, and PT is diabetic. Diabetes and or history of is a "risk factor" for medical decisions and treatment plan with steroids, but not likely a DX for the epidural (provider is not managing the Diabetes). Provider addendums are valid at any time, espeically when filing a corrected claim as appropriate.
 
Let me try to address each question as listed. I am assuming for all scenarios, this is for outpatient pro fee coding.
1. You only code diagnoses that are being treated, or affect treatment. For example if pt has HTN, but you are an ortho treating a mild sprain without surgery or medication, the HTN would usually not be coded. If that same pt has HTN, and you are an ortho treating a fracture surgically and want medical clearance first due to the HTN, then the HTN would be coded as it affects treatment. Particularly with shared medical records in large multispecialty groups, it can sometimes initially look like there should be 20 diagnoses. For chronic problems on the active problem list in those situations, providers should be educated to note if the other problems not being treated affected what the clinician is treating
2. Cancer that is no longer being treated, and in remission is typically coded as history of Z85.##. The older school of thought is cancer diagnosis within 5 years is coded active C##, and only becomes history after 5 years in remission. The newer advice is once the cancer is removed, no recurrence, and no longer being treated, you would code history of even if < 5 years. A patient receiving chemo or any current treatment is coded as active cancer. This is all assuming you are the physician treating the cancer, or the cancer affects what you are treating the patient for.
Specifically from SGO coding advice:
How long can you use the cancer diagnosis (C56.1-9) for a patient once they have completed treatment?
Historically the primary cancer codes were used until the patient had been in remission for 5 years. However recent guidelines state that when the primary has been previously excised or eradicated from its site, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy at that site, it is appropriate to use the personal history code. Both are recognized for patients who are on surveillance. For patients on treatment, including maintenance, the primary cancer code should be used.
3. Yes, an addendum is meant to correct a medical record that was unclear, missing info or incorrect originally. Definitely use the corrected information.
4. You can count and code the information in the medical record regardless of what heading it is under. It's obviously easier and clearer if the information is under the appropriate heading to avoid misunderstandings. I would use it as an educational opportunity if I had a clinician continually doing this.
 
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