Sick Sinus Syndrome with Pacemaker

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I recently passed the CPC exam, though I have been working as a risk adjustment coder for nearly a year. There was a scenario wherein the patient has SSS and also has a pacemaker implanted. While I do understand that we cannot code the SSS as active if no attention or treatment is provided to the condition or the pacemaker, is it appropriate to code it as a history if it is pertinent to the scenario?

Please help me with some hard facts and literature. Thank you.
 

Orthocoderpgu

True Blue
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Salt Lake City, UT
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Even if a medical condition is not being treated by the physician during the visit, if the physician has to really consider the influence of that medical condition because it will effect a medical condition being treated, you can code. However, your physician needs to document it in the assessment. Diabetes and HTN effect virtually everything, so even if a physician is not treating the diabetes and HTN, because your physician will need to take into account how any treatment will effect these medical conditions, they may be listed and billed. But again, your physician needs to document any medical condition not being treated, but does influence their medical decision making in the assessment.
 
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Cavite, MM
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Thank you very much for the reply. I do understand that you can code a diagnosis if it really affects the conditions listed in the assessment. However, I am really confused about the coding of SSS as a history. A history code should only be used if the patient has a medical condition that no longer exist and is not receiving any treatment. The pacemaker is treating the SSS or it is still the underlying condition for the pacemaker implantation. Would it really entail the coding of its history on this scenario?
 
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