Wiki Question

[12scrapbooker]

One of my docs said if the patient has hypertension and/or CKD and they come in for a sick visit - you have to put the dx codes of the hypertension, CKD and BMI on that sick visit. I wasn't sure of that and wanted to ask. My other doc said no - you can just dx the patient with the sick dx code. Any help is appreciated. Thank you

 

[rthomas@impcna.com]

One of my docs said if the patient has hypertension and/or CKD and they come in for a sick visit - you have to put the dx codes of the hypertension, CKD and BMI on that sick visit. I wasn't sure of that and wanted to ask. My other doc said no - you can just dx the patient with the sick dx code. Any help is appreciated. Thank you

You only code what is addressed and treated. Just because a patient has a chronic condition doesn't mean it gets coded it at every visit. If the patient was seen and final dx was URI then that is all that is coded. Now if the patient came in for URI, BP elevated or needing meds refilled and there is documentation of that then yes, you would code the HTN.

 

[csperoni]

Agree with @rthomas@impcna.com. I would just add that a diagnosis that affects the treatment may also be coded (assuming it is documented). So when treating the acute illness, if the provider was going to prescribe one treatment, but then prescribed another due to CKD, then coding the CKD as secondary would be appropriate.