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Thread: Chronic Conditions Listed in PMH

  1. #21
    Join Date
    Apr 2007
    Location
    Dover Seacoast New Hampshire
    Posts
    1,912

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    Promo: Code Books
    eagonoy, the OP is discussing outpatient facility coding, not physician coding. In this case, E&M guidelines do not apply, and you would report all codes related to the patient's medical history, as relevant to the current episode of care.

    In the facility setting, chronic conditions are reported for data purposes, as well as to support any adjunct therapy provided while the patient is admitted in the outpatient setting.

    We report those conditions stated in all related physician documentation that would/could impact treatment of the current condition. We also include history, if it's relevant to the current care. Experienced coders understand which diagnoses to include, and which can be left off. But to assume you have to code only based on what the provider is currently treating, would be inappropriate in the outpatient setting.
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  2. #22

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    Pam - you're correct.. however not every coder is so experience that they can tell right off what can be coded and what can't thus then need for documentation, yes?

    "We report those conditions stated in all related physician documentation that would/could impact treatment of the current condition. We also include history, if it's relevant to the current care"

    You mean in the entire medical record? what if only the record for the encounter in question is available? that means we need clear documentation, correction?

    thank you, !!
    Rebecca Torres

  3. #23
    Join Date
    Apr 2007
    Location
    Dover Seacoast New Hampshire
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    1,912

    Default

    Depending on the type of outpatient record, there should always be an order, a H&P (a requirement for admission) and the physician note specific to the outpatient service. You may code from all three. You may not code from nursing notes. Other OP services have other documents, and not all OP services are coded based on a physician's note (outpatient labs, for example are coded from the order). If these are not in place, the medical record could be incomplete.

    It does take experience, but it also takes an understanding of pathophysiology and disease process so that you can identify the appropriate diagnoses to report.
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

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