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Coding Co-Morbid Conditions

  1. #11
    Medical Coding Books
    If you do provider training on documenting you may want to encourage them to be thorough when documenting the problems they need to take into consideration and mention something in the A/P, e.g., pt. will receive reduced strength chemo due to underlying heart condition.

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    We do not use the list of DX history. Only those which will effect the way the patient is treated at the visit.

    For Example, a patient with Epistaxis. If they also have Hypertention, anemia or coagulation defects, we always list those diagnosis since they are involved in decision making for this visit and current condition.
    Rachell Lindley, CPC
    Multispecialty Clinic Coding
    Internal Medicine
    General Surgery
    Family Medicine

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    I think it's appropriate to list the diagnoses, but not to use them to increase MDM unless "...the record clearly demonstrates their presence increase physician work related to the enounter". If the physician listed the dx under A/P, and notes that they are managing their medications, etc., then it would be appropriate for the dx to increase the MDM.

    Megan B, CPC

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