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Asthma check

  1. #1
    Question Asthma check
    Exam Training Packages
    Pt came in for an asthma check and med refill. Assessment states history of asthma good control. They renewed his meds. Icd9 for this?? Thanks

  2. #2
    Location
    Harrisburg
    Posts
    20
    Default Asthma
    Since asthma was treated (med renewal), I would code this as current asthma

    Andrea
    CCS, CCS-P, CPC

  3. #3
    Location
    Stuart, Florida
    Posts
    331
    Default
    Helen,

    Do you have the opportunity to speak with the doctor about the use of the term "history"? If the doctor documents hx of, but really means that the patient still has whatever the "hx of" may be, you should take the documentation back to the doctor and educate them on the use of the word history.

    Under ICD-9 Guidelines, the term "history of" means that the patient no longer has the condition. Never use this term to describe a disease that the patient still has.

    Now I understand that, since the patient is obviously still receiving medication for this condition, it is still a pertinent diagnosis. I'm unsure what kind of coding you do but, from my experience working in a physician office setting, I can tell you that we have had DXs that did not validate because of the use of the term "history" even though it was a chronic condition. Information in the subjective portion of the note clearly showed that the diagnosis was valid. However, in the Assessment portion, the diagnosis was written as "History of COPD" for example.
    Vanessa Mier, CPC

  4. #4
    Default
    Thanks alot. I thought we should use the asthma diag but another coder in the office billed with history of asthma which was denied by blue cross. I will appeal with correction. I will also speak with the Drs to let them know how to use "history of". Again thanks!

  5. #5
    Location
    Stuart, Florida
    Posts
    331
    Default
    Quote Originally Posted by HBULLOCK View Post
    Thanks alot. I thought we should use the asthma diag but another coder in the office billed with history of asthma which was denied by blue cross. I will appeal with correction. I will also speak with the Drs to let them know how to use "history of". Again thanks!
    You SHOULD be using the asthma code, as the patient does have asthma, but the documentation must match. All that needs to be done is a correction addendum clarifying the diagnosis. I mean, I get it, the doctor means that the patient has a long history of asthma. Let's be honest though, we know that insurance companies don't want to pay so they will use what they can to deny payment. This is an especially difficult subject to drill into doctors' heads because they see it as a sneaky way to deny based on a play on words.
    Vanessa Mier, CPC

  6. #6
    Location
    International Member
    Posts
    215
    Default
    Hey,

    I think V68.1 is appropriate code for this encounter.

    As per ICD 9 CM => Issue of repeat prescriptions.

    Also regarding Asthma, then if you're coding chronic conditions for which patient is on medication then you may add 493.9* as a SDx.

    Hope this helps!!!

    VJ

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