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Thread: Past Medical History

  1. #1

    Default Past Medical History

    Is there a list of chronic conditions that is acceptable to code when listed in PFSH/PMH (and often times not mentioned any further in the office note)

    Thank you
    Last edited by chandler80; 11-19-2008 at 02:07 PM.

  2. #2
    Join Date
    Apr 2007
    Location
    Milwaukee WI
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    4,453

    Default Not treated = Not coded

    If the chronic condition is mentioned ONLY in the history and is not being evaluated or treated, then I wouldn't code it.

    But perhaps I'm not understanding your question ...

    F Tessa Bartels, CPC, CPC-E/M

  3. #3

    Default

    I agree with Tessa. A chronic condition or any condition for that matter should only be coded if it is addressed and treated in the A/P. Perhaps I am not understanding your question either. Let us know if we can help further!
    ~Amy, CPC, CPMA, CEMC~
    Auditor/Consultant

  4. #4

    Default

    I was taught to code chronic conditions such as DM, HTN, and any that might have bearing on what pt is being treated for, such as GERD, COPD, CAD, etc... I have also been told to code all chronic conditions, as it gives "the BIG picture." Is this wrong? (I do ER coding in a hospital.)

  5. #5
    Join Date
    Apr 2007
    Location
    Houma, La.
    Posts
    35

    Smile Guidelines

    According to the ICD-9-CM Guidelines, Section IV-k, Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. I hope this helps. You can find a lot of answers to questions in the Guidelines!

    Sally Thibodeaux CCS,CPC,LPN
    Houma,La. Chapter

  6. #6
    Join Date
    Apr 2007
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    Milwaukee WI
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    Default Whose the doctor?

    I did not examine the patient. I did not take the history. I'm not a doctor (or any other healthcare provider). I don't know if the DM mentioned in the history has any impact on the broken ankle unless the doctor states so in the documentation.

    If it's just in the history section with no further mention, I don't assign a Dx code.

    The provider should document what was done. The coder should code what was documented.

    F Tessa Bartels, CPC, CEMC

  7. #7

    Default

    Thanks, sthibo! That's what I thought, but it certainly wouldn't hurt me to review the guidelines periodically!

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