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ICD-9 Coding from “Problem List”

  1. Default ICD-9 Coding from “Problem List”
    Medical Coding Books
    We are currently having a debate on coding from a problem list. Pt is here to be seen for “routine physical” which is CC.
    HPI states pt is doing well from previous visit and does not complain of any symptoms.
    No abnormal findings from physical. Pt is 71 years old.
    Physician then list 10 to 12 DX from patients problem list.
    Physician then states will order routine lab.

    Question: from this scenario, can we code labs from this problems list?
    When would it be appropriate to code from a problems list?


  2. #2
    Columbia, MO
    This is a routine annual which gets a V70.x as the first listed, the "other" dx may be listed as additional dx if they were managed controlled or treated at this encounter. If the patient is on current medications and the labs are ordered to check the medication the code a V58.83 and V58.6x for the labs, otherwise if the labs are ordered for screening purposed then code screening. Hope this helps!
    Debra Mitchell MSPH, CPC-H

  3. #3
    If the patient is in for a physical and labs are done for a certain medical condition they have, maybe high cholesterol or diabetes, and that is noted in the note, I code the labs with those - for example, the lipid panel with 272.4 and A1C with 250.00.

    The provider should document that they addressed those chronic conditions and if they did, the diagnoses can be used.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    National Advisory Board Member 2018-2021, Region 6 Great Lakes
    Minneapolis AAPC Chapter, Education Officer 2018
    AHIMA ICD-10-CM/PCS Trainer
    AAPC National ICD-10 Trainer

  4. Default
    Thank you this does help

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