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peanutbutterkisses

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Good morning,

I wanted a second opinion about this chart. What would you say is the Cheif Complaint? How would you code this chart?

INTERIM HISTORY:
This is an 68 year old male with history significant for CAD, DM2,
HTN, atrial fibrillation on warfarin, PVD s/p L AKA, vascular dementia, and
neurogenic bladder + BPH, with recent admissions for colonic pseudo-obstruction.
Vet has recently been treated for recurrent uti and has indwelling catheter. Vet
has recently been given a motorized scooter and is very happy. Mood has
improved.

_______________________________________________________________________
REVIEW OF SYSTEMS:
Vet has no complaints, denies sob, cp, palpitations, n/v or
diarrhea/constipation.



_______________________________________________________________________

Medications dispensed from VA facilities.
Non VA medications as documented and/or reported by patient/surrogate:
==================================================================
Active Inpatient and Outpatient Medications (including Supplies):

Inpatient Medications Status
=========================================================================
1) ACETAMINOPHEN TAB 650MG PO Q6H PRN Administer as ACTIVE
needed for Mild pain (pain score 1-4)
2) ARTIFICIAL TEARS SOLN,OPH 2 DROPS OU Q4HA PRN may ACTIVE
refuse dry eye
3) ATENOLOL TAB 50MG PO QDAY Hold for SYSTOLIC BLOOD ACTIVE
PRESSURE <110 and HR <60
4) ATORVASTATIN TAB 40MG PO QHS ACTIVE
5) CALAMINE/LANOLIN/MENTHOL/ZINC OXIDE SMALL AMOUNT TOP ACTIVE
TID PRN excoriation
6) CITALOPRAM HBr TAB 20MG PO QDAY ACTIVE
7) FINASTERIDE (DO NOT CRUSH) TAB 5MG PO QDAY ACTIVE
CHILDBEARING AGE FEMALE HANDLE WITH CAUTION *
HANDLE WITH GLOVES
8) HYDROXYZINE TAB 25MG PO Q6H PRN pruritus ACTIVE
9) LISINOPRIL TAB 5MG PO QDAY ACTIVE
10) POLYETHYLENE GLYCOL POWDER,ORAL 1 PACKET (17GM) PO ACTIVE
QDAILY PRN
11) POTASSIUM CHL (K-DUR) TAB,SA 40MEQ PO BID ACTIVE
12) PSYLLIUM (SUGAR-FREE) POWDER,ORAL 1 PACKET PO DAILY ACTIVE
13) QUETIAPINE FUMARATE TAB 25MG PO Q4H PRN Max: 3 prn ACTIVE
doses Q 24hours; for agitaion/combativeness
14) SENNA (187MG [8.6MG SENNOSIDES]) TAB 17.2MG PO ACTIVE
TU-TH-SA@HS PRN
15) TAMSULOSIN CAP,ORAL 0.4MG PO DAILY ACTIVE
16) THIAMINE TAB 100MG PO QDAY ACTIVE
17) WARFARIN (HIGH RISK) TAB 5MG PO D5 start 1/8 No ACTIVE
coumadin today 1/7

Outpatient Medications Status
=========================================================================
1) ATENOLOL 50MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY HOLD
FOR HEART
2) FOLIC ACID 1MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY HOLD
3) FUROSEMIDE 40MG TAB TAKE ONE TABLET BY MOUTH EVERY HOLD
MORNING
4) GAUZE,PACKING IODOFORM 1/2IN X 5YD USE GAUZE HOLD
TOPICALLY EVERY DAY LIGHTLY PACK WOUND FROM LATERAL
SIDE.
5) NICOTINE 14MG/24HR PATCH APPLY ONE PATCH TOPICALLY HOLD
EVERY DAY AFTER REMOVING OLD PATCH (FOR EXTERNAL
USE ONLY)
6) TAPE,DURAPORE 1IN 3M #1538-1 TAPE EVERY DAY (FOR HOLD
EXTERNAL USE)
7) TRAZODONE HCL 50MG TAB TAKE ONE TABLET BY MOUTH AT HOLD
BEDTIME

24 Total Medications
==================================================================
No Active Remote Medications for this patient
PHYSICAL EXAMINATION:
Gen: awake and alert, no acute distress
HEENT: EOMI, no lymphadenopathy, moist mucosa
Lungs: cta
Heart: rrr
Abd: snt, +bs
Ext: no peripheral edema
Skin: intact
97.2 74 17 123/75 91%RA
_______________________________________________________________________
RECENT LABORATORY:
INR-2.5

_______________________________________________________________________
RECENT CONSULTS:
Dental, psych-started on quetiapine prn and rehab seating

_______________________________________________________________________
ASSESSMENT/PLAN:
Left aka-will monitor scooter use, consult placed for gel chair
frequent uti-monitor s/s
afib-inr therapeutic, for recheck next week.
code status to remain dnr
 
I should have mentioned that this is a subsequent Nursing Facility Visit. The dx selected by the physician was 997.60 Amputation Stump Complication NOS

My understanding is the principal diagnosis should be the condition that is cheifly responsible for the continued residence. Because he states that the patient has no complaints, I do not feel it is codable as is. I am not able to query the provider as I am auditing this chart only. I don't see a Cheif complaint. Even if it is for followup of chronic conditions, it should be stated.

Thanks for the help
 
The code chosen by the provider is not supported by the documentation. Amputee status is an allowable first listed V code but I would use it with a follow up code. But this looks like a stable patient that the provider is just making rounds on. Therefore the choice of dx codes is limited to the V codes for a first listed dx.
The nursing facility billing is the reason for the patient to be there. The provider encounter dx is based on that days encounter.
 
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you are correct- per CMS, a medical chart must always state a cc. I don't agree with using a V code primary and no other codes though. I work in internal med and majority of encounters are for HTN mgmnt, DM mgmnt etc. I don't code a V code. I code the medical conditions that the patient has.
 
Sometimes the V code is the correct code and some are only allowed first listed. If the patient has no complaints and the visit is follow up then it is a V code first listed. I disagree with the logic that you never use V codes for a visit. Sometimes a v code is exactly what the claim needs.
ICD-10 CM has changed the follow up codes so perhaps it will not be as confusing for when to use it. But you cannot use a code that the patient does not have at this encounter.
No cc only means that history cannot be counted as an element of the encounter. If all three elements are required for the desired level then with no cc there can be no visit level. But if it is a level where only 2 components are required you can code the encounter.
With the information given in the example, the dx code is a V code.
 
Per CMS 1997 guidelines, a cc must be documented...

I never said you can never use a V code primary. I said that I always code the condition the pt has if the dr is treating/following the patient for that said condition.

Also, please Deborah, don't put words in my mouth. I also notice your cert is hospital based and not CPC physician. I can direct you to AAPC's guidelines in regard to this topic if you prefer.
 
The cc is that this is a routine subsequent visit.. The provider states there are no complaints, so if you will then, no complaints is the cc that is as good as it gets for these kinds of encounters. He gives history of and status post as the diagnosis. You can't make anymore out of this. I see these all the time and a follow up code works just fine.
 
you are assuming this visit was for "routine follow up". The provider/clinical staff must document a chief complaint. A coder cannot and should not assume the reason for the encounter. This is basic coding knowledge.
Unless I am way off base, the provider ordered labs due to the pt's afib & also a DME to avoid ulcers due to pt's amputation. Most Payers do not reimburse for this routine V code. Sure they do for V70.0, V76.31, V20.0 V20.2 etc....
Why wouldn't afib be coded?
 
VAMROC records are always very hard to read and decipher. When I worked for a disability lawyer I had to try to read these peices of cryptic documents. The CC is what ever they came in for and as he left AMA this does not bode well. They also, somewhere in the record, have their % of the war or enlistment disabilities. Those are the main reason for any VA encounter.
 
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BenCrocker said:
VAMROC records are always very hard to read and decipher. When I worked for a disability lawyer I had to try to read these peices of cryptic documents. The CC is what ever they came in for and as he left AMA this does not bode well. They also, somewhere in the record, have their % of the war or enlistment disabilities. Those are the main reason for any VA encounter.
Click to expand...

I'm not seeing that the patient left AMA in the OP's post....I see "left aka"...is that what you're referring to?
 
Thank you all for responding. I think I agree with @teresabug in this regard. I think this documentation is too unclear...Was it a follow-up of the recent UTI, afib. I would code the a-fib, hx UTI, status AKA, long-term wafarin, but there is no CC.
 
BenCrocker said:
VAMROC records are always very hard to read and decipher. When I worked for a disability lawyer I had to try to read these peices of cryptic documents. The CC is what ever they came in for and as he left AMA this does not bode well. They also, somewhere in the record, have their % of the war or enlistment disabilities. Those are the main reason for any VA encounter.
Click to expand...

I am not seeing that there is any mention of leaving AMA either. This is stated as an inpatient encounter. The CC is stated by the provider:
"has no complaints, denies sob, cp, palpitations, n/v or
diarrhea/constipation."
That is an acceptable CC. You cannot create a complaint when clearly the patient does not have one. When a patient is in the inpatient setting the attending is required to make so many subsequent encounters. This is just a subsequent routine encounter for a patient with an amputation that is on medication for chronic problems. You can code the V code for therapeutic drug monitoring with the V code for the drug status, you can code the V code for the amputee status. You cannot get anymore from it. Clearly there are no problems for the provider to address outside of routine drug monitoring.
If this patient were not in an inpatient setting, they would not have been in the providers office on this day for medical services.
 
Semantics?

Interesting discussion - I agree with Debra - sometimes there is just no complaint and nothing is "wrong" - it may be just a follow-up. If so, that is why the patient is there and that would be the "chief complaint." Even if it doesn't match the Meriam-Webster definition of "complaint."
 
The lab ordered was due to the medication the payient is on to control the A fib, not because there were issues with the a fib. Coding clinics have stated that this is to be coded as therapeutic drug monitoring with V58.83 and the appropriate V58.6- code for the drug.
 
page 107 of the AAPC CPC guide clarifies that when a patient's record documents a vascular disorder and it also states the a patient is taking or has a long term use of an anticoagulant, to report V58.61 as an additional diagnosis

This patient is having medical care rendered by a provider for a current medical condition of afib. Myself and countless providers in my 18 year career have always listed the medical condition on the claim form before any V code. I don't disagree to not list a medical management V code, but I do not agree that it is the only code to be billed.

Maybe an AAPC moderator can step in on this thread to help clear up any confusion.
 
teresabug said:
page 107 of the AAPC CPC guide clarifies that when a patient's record documents a vascular disorder and it also states the a patient is taking or has a long term use of an anticoagulant, to report V58.61 as an additional diagnosis

This patient is having medical care rendered by a provider for a current medical condition of afib. Myself and countless providers in my 18 year career have always listed the medical condition on the claim form before any V code. I don't disagree to not list a medical management V code, but I do not agree that it is the only code to be billed.

Maybe an AAPC moderator can step in on this thread to help clear up any confusion.
Click to expand...
I will make one last attempt to clarify my position. The coding guidelines specify that the first listed dx code needs to reflect the reason for the encounter (the chief complaint), that condition which the visit is concentrated on. Now you say this should be the Afib. Here is what the doc wrote:
This is an 68 year old male with history significant for CAD, DM2,
HTN, atrial fibrillation on warfarin, PVD s/p L AKA, vascular dementia, and
neurogenic bladder + BPH, with recent admissions for colonic pseudo-obstruction.
Vet has recently been treated for recurrent uti and has indwelling catheter. Vet
has recently been given a motorized scooter and is very happy. Mood has
improved.
Out of all of these conditions which are are simple listed you pick Afib and say that is the reason for the encounter. The reason for the encounter is clearly stated as no complaints. I am disagreeing with simple picking one from the "problem list" and stating this is the principle dx. All the provider did was to see the patient and assure that he was in good spirits and indicated the most recent INR result. Again if this patient were not in the inpatient setting, there would have been no reason for a physician encounter. None of the chronic conditions were managed or controlled, no meds were changed, nothing was symptomatic. I think it is confusing to instruct that a coder should go thru this problem list and identify one dx as the principle. I also do not feel that the provider has poorly documented this encounter, and to send it back to the provider for more information would be the wrong thing to do.
Many coders do not like choosing a V code for a first listed code, but sometimes it is the correct choice.
 
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so technically this visit does not even qualify as being medically necessary based on the above. No cc documented. I would query the provider then and asked why he even rounded on the pt. I've audited providers that round on patients and document "pt is asleep" then try to bill an E/M.
 
mitchellde said:
I am not seeing that there is any mention of leaving AMA either. This is stated as an inpatient encounter. The CC is stated by the provider:
"has no complaints, denies sob, cp, palpitations, n/v or
diarrhea/constipation."
That is an acceptable CC. You cannot create a complaint when clearly the patient does not have one. When a patient is in the inpatient setting the attending is required to make so many subsequent encounters. This is just a subsequent routine encounter for a patient with an amputation that is on medication for chronic problems. You can code the V code for therapeutic drug monitoring with the V code for the drug status, you can code the V code for the amputee status. You cannot get anymore from it. Clearly there are no problems for the provider to address outside of routine drug monitoring.
If this patient were not in an inpatient setting, they would not have been in the providers office on this day for medical services.
Click to expand...

CPT states "A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patient

I was always taught that even when there an absence of symptoms and the patient is being seen for a follow up, those conditions should be specified i.e "pt seen today for a follow up of recent UTI" Simply stating "follow up" or "no complaints" because is not specific or concise. Even if pt's chronic conditions are well controlled i.e. DM or HTN and the patient is currently symptom free, it is still a folllow up of that condition.
From Coding Clinic, 4th Q 2003
In long term care, the principal diagnosis is defined as the condition chiefly responsible for the admission to, or continued care in the nursing facility. If coding diagnosis during the residents stay, the condition chiefly reponsible for the continued stay is still the principal diagnosis.
 
That coding clinic is referring to the facilities codes. Not the provider encounter codes. In any inpatient setting the provider must make rounds on the patient, not the other way around. In a VA hospital for a military issue a discharge comes after several phases. So essentially there may be no current active medical issues and the patient can till be in patient. So it is logical,and reasonable that the patient has no complaints. And that is a good thing. So the provider encounter per the patient chief complaint is that he has no complaints. He has no active symptomatic concerns, and the coder cannot give them one.
In the absence of symptoms for a follow up visit, if the patient is still undergoing treatment then guidelines state to code this as aftercare, and if there is no active treatment it is follow up, these are V codes.
I do not understand why you think the payient must have an active dx to code the encounter.
How would you code a visit post appendectomy? Just a routine 6 month follow up? It us a V code for follow up.
This visit is no different
 
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