Reporting all diagnoses in the assessment?

ShannaRoe

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Nora Springs, IA
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Hello all--I would like to know your opinion on reporting all diagnoses in the assessment in the clinic setting, whether they are being treated or not.

For example, patient comes in for hypertension medication refill and monitoring, and has anxiety and a history of a healed traumatic fracture. The only thing treated/addressed at the visit is hypertension, but in the assessment the physician lists: hypertension, anxiety, and history of healed traumatic fracture.

Which diagnosis codes would you report and which ones would you leave off in the clinic setting (assuming that all diagnoses had been reported earlier in the year for risk adjustment purposes). This is something of a debate in our office and I am very interested in opinions.

Thanks!
 
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Coeur d'Alene, Idaho
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If it appears as though the provider has just brought the problem list down into the assessment and plan area without some further comment on each condition, I, personally, don't code it. I like to use the MEAT or TAMPER mnemonic when deciding whether or not to capture a dx and educate our coders and providers to this. MEAT stands for monitor, evaluate, address/assess, and/or treat. TAMPER stands for treat, address/assess, manage, prescribe, evaluate, and/or refer. I'm interested to see what other opinions are.
 
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Selden
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I agree with Amanda. Especially with EMRs, it's very easy for a previous list to just pre-populate or carry over.
I code only items we treat or impact how we treat. In your example, I certainly wouldn't use the history of fx. Basically, that could be used on practically every single patient depending how far back you inquire. IF the anxiety were contributing to the HTN, or there was a potential rx interaction, so a medication was changed, that would be coded. Assuming the provider documented such.
 
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