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Thread: Coding from the PMH?

  1. #1

    Lightbulb Coding from the PMH?

    AAPC: Back to School
    Another question:

    Can you code diagnosis (chronics) from the PMH? The Provider doesn't mention it in his A & P.

    Not sure how true it is but someone told me if you are already counting it in the patients history you can't pull it from there and code it unless the provider mentions it in the A&P.


    Thank you!

  2. #2


    I work in the Medicare Operations/Risk Adjustment department of a major health insurance company as a coding auditor. Per CMS guidelines, Old MI (412) is allowable from pmh only. In the case of chronic conditions (ie, DM or COPD), in order to "capture" these codes for this DOS, the condition must be addressed during the course of the visit. For example: COPD is listed in pmh but not the A or P. Search the office note. Is the patient on medication specifically for COPD and the physicians notes the continued use and daily dosage? Did the physician listen to the lungs and make note of findings? Even if no s/s of COPD are present...the fact the physician addressed the respiratory system is enough to justify an evaluation of the status of the COPD.

    So...only Old MI can be taken from pmh only. All other chronic conditions must be addressed in some way during the visit in order for the code to be included for that DOS.

  3. #3
    Join Date
    Apr 2007
    Stuart, Florida


    I disagree with your statement that ALL other chronic conditions must be addressed in some way during the visit in order to code them. There are exceptions to this rule, as long as the patient is documented as having the condition on the DOS in question. For instance, the example you used of DM.

    The following is a quote taken directly from the coding guidelines/coders' desk reference for diagnoses:

    "Diabetes is a systemic disease and, as such, should be coded even in the absence of documented, active intervention during the patient encounter."

    I did not post a response to this post, originally, because this question has been asked and discussions have been had on this subject numerous times in the forums. If you do a search for "PMH" or "Chronic Conditions" I'm sure you'll pull some of those threads up. In my experience, I've found that different insurance companies interpret the the guidelines in different ways and tend to make up their own rules anyway. If I had it my way, this would not be the case. There has already been a standard set and we should all have to stick by it. Unfortunately, there is still so much of coding falling in the "grey areas". I'm sure you've seen it said again and again, "Coding is not all black and white... there is a huge grey area."

    It is my personal opinion that all DXs should be addressed. It's also my opinion that the coding guidelines need to be expanded and made to be cohesive from start to finish. Also, I feel that doctors need to be held more accountable for their documentation, or lack thereof.

    EDIT: I wanted to clarify further, just in case. I'm referring to coding chronic conditions not addressed in general, not specific to PMH. I do, both, HCC and FFS coding. HCC, as you may be familiar with, pays on the DX codes. The insurance carriers in which we are involved with HCC do not accept ANY codes taken from documentation outside of the Assessment portion of the notes. They will allow the doctors to address the diagnoses listed in the assessment portion throughout the body of the note but if the diagnosis, itself, is not listed in the assessment than it may not be coded. Obviously, to me, this is just a sneaky way to try and hold out payment for something. However, as a coder, should you run into this type of scenario, you should bring the documentation back to the doctor and inform him/her of the omission BEFORE coding and processing of the claim.

    The above response pertaining to the rule for systemic diseases and chronic conditions listed in PMH is not in referrence to HCC coding, as that is an entirely different animal. Although, once I brought this up to the head of our MRA department, it was brought to the attention of validation and is now being recognized.
    Last edited by ohn0disaster; 04-06-2011 at 10:55 AM.
    Vanessa Mier, CPC

  4. #4


    Thank you I appreciate the feedback!

  5. #5


    Not sure how true it is but someone told me if you are already counting it in the patients history you can't pull it from there and code it unless the provider mentions it in the A&P.

    Just responding to the part of the phrase where someone told you that you can't code from the PMH - that person is wrong. You most certainly can code from the PMH, assuming the other conditions and guidelines mentioned by the other posters are present

    Obviously, your mileage may vary, depending on the documentation and the nature of the condition; I just had a problem with that blanket statement

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