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Coding Co-Morbid Conditions

  1. #1
    Location
    Utica New York
    Posts
    22
    Default Coding Co-Morbid Conditions
    Medical Coding Books
    We are wondering if you audit a chart for say bronchitis but the patient also has one or all of the following listed in the PAST HX. if you use it as well. The dx. being..... hypertension, diabetes, Parkinson's, COPD, etc. We are not using them if the provider is not addressing them but are now questioning ourselves.

    Thank you for your help.
    Lisa
    Lisa M. Toth Brosey, CPC
    Faxton St. Lukes Healthcare
    Utica, NY

  2. #2
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    Quote Originally Posted by Ltoth View Post
    We are wondering if you audit a chart for say bronchitis but the patient also has one or all of the following listed in the PAST HX. if you use it as well. The dx. being..... hypertension, diabetes, Parkinson's, COPD, etc. We are not using them if the provider is not addressing them but are now questioning ourselves.

    Thank you for your help.
    Lisa
    In our office we don't list them either, unless they are being addressed. Alot of times we see the "laundry" list of ailments but if they have no effect on treatment of the current condition and are just mentioned in past history then no we don't count them.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
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    Here, we do use all of the dx's. That is mostly for our ER charts, though. We sometimes need them for additonal labs & tests done while the patient was here. We also use all dx's listed on the superbill for our clinic visits. Also, it states in the guidelines (on page 90) to "list additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established by the physician." Hope this helps. I think everyone codes a little different and other people tend to interpret things different ways so this is just my opinion and my way of coding.

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
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    I agree with Roxanne. I only code the current conditions addressed, not from the history or chronic conditions list.
    Lisa Bledsoe, CPC, CPMA

  5. #5
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    Most times it won't make a difference in the E/M level since you have a new problem that will require rx management. But you need to keep in mind that even though they aren't addressing the HTN, DM, etc directly, if the patient is on meds for chronic conditions they have to take those in consideration before they can write another script. So even though they may not be focusing on the HTN today, they are still dealing with it.

    Just my thoughts,

    Laura, CPC

  6. #6
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    Sometimes underlying conditions do influence decisions - as stated in Laura's example - and in such cases I do count those. If they don't have an impact, I would not count them. I would credit Past History and also consider all the conditions the patient has to deal with when looking at the table of risk. Even if the provider is not currently actively dealing with the issue(s), it still adds to the risk for the patient.
    Karolina, CPC

  7. #7
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    Quote Originally Posted by Karolina View Post
    Sometimes underlying conditions do influence decisions - as stated in Laura's example - and in such cases I do count those. If they don't have an impact, I would not count them. I would credit Past History and also consider all the conditions the patient has to deal with when looking at the table of risk. Even if the provider is not currently actively dealing with the issue(s), it still adds to the risk for the patient.
    Karolina, CPC
    I do understand your point of view on this topic I guess I am used to my physicians listing those types of conditions elsewhere not only in past history. My docs will list them w/ the a/p part of the note, not just in the Past history.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  8. #8
    Default to rthames052006
    I agree with that, mine do to. In the given example it seemed limited to the past hx. Thanks!

  9. #9
    Default
    Quote Originally Posted by Karolina View Post
    I agree with that, mine do to. In the given example it seemed limited to the past hx. Thanks!
    Karolina....

    I'm glad we were on the same "wave length".
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  10. Default
    We had to write a SOP to this effect to cover ourselves when outside auditors came in to review our records as part of our CBI plan. Some auditors would pick up the ALL chronic conditions while others limited the diagnoses to the A/P- which is what our SOP stuck with the provider's A/P documentation!!

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