Wiki Reading of MD/NP notes

[kristenderosa@gmail.com]

I am relatively new to the world of coding and I have a general question when reviewing provider notes.

When reading a provider note, is it okay to pull codes from the Patient Active Problems List? Usually, I will look through the HPI and the A&P sections to determine which codes I need for each resident that is being admitted to the SNF from the hospital. In some cases, the active problems are not listed in either the HPI or the A&P section but are chronic in nature.

Any help would be greatly appreciated! Thank you

 

[TThivierge]

Hi! It depends on your coding protocol at your work site. Personally, I would look into the physician or clinical provider's Physical Exam or assessment section to see what he or she documents. At my job we can add the active problem list (comorbidities or complications) to enhance whatever the patient is being currently treated for this day. Or it should be related. Some believe current ongoing conditions or chronic such as DM, COPD, Cardiac Conditions, CHKD, HTN, Hyperlipidemia, Hypothyrodism, Depression, Anemia or Arthritis should be added since it may affect the current illness in the category of synergistic risk.
More tips if the doc adds documentation of "Chronic or Acute" certain illness add the corresponding Dx. do not just use the unspecified diagnosis. Use the appropriate Z dx. encounter /health status codes per the provider documentation and if related to current illness. I have worked under past coding manager say it is a waste of time to use Z dx. code when in the last place on the claim. If the patient has DM2 ensure add Z79.4 or Z79.84 per medication use and doc says. Be aware of the Excludes rule 1 too. There is difference in oral vs insulin. If the patient has amputation or cardiac devices in body; add those dx. Also ensure if injury dx. code; use the place of occurrence, and how injury happened and hopefully the date it happens is on record. Your coding depends on coding protocal at your work site AND clear documentation from your physician.

I love this profession of reading & abstract clinical coding in a sense "Every Patient has A Medical Story" I hope you will keep loving it too. Good Luck!!
Lady T