Results 1 to 4 of 4

Diagnosis help on chronic conditions

  1. #1
    Location
    Harrisburg, PA
    Posts
    14
    Question Diagnosis help on chronic conditions
    Exam Training Packages
    I am auditing a patients chart and am coming across a documentation discrepancy. The doctor documents in the CC "Patient presents for hypertension, hyperlipidemia and diabetes. patient continues to follow up with providers for his ca prostate and bladder. c/o stinging, itching both feet" but then in the HPI only discusses the diabetes. In the MDM of the note he blows in every dx mentioned in the HPI (Diabetes, hypertension, hyperlipidemia, anemia, carcinoma prostate, carcinoma bladder). I believe only the diabetes is supported based on this documentation. Can you use a dx if it isn't mentioned the status of it? Under the dx of diabetes there were labs ordered and follow-up. The other dx's listed only say "Patient voiced understanding of the instructions." Any suggestions????

  2. #2
    Talking
    Quote Originally Posted by adweaver View Post
    I am auditing a patients chart and am coming across a documentation discrepancy. The doctor documents in the CC "Patient presents for hypertension, hyperlipidemia and diabetes. patient continues to follow up with providers for his ca prostate and bladder. c/o stinging, itching both feet" but then in the HPI only discusses the diabetes. In the MDM of the note he blows in every dx mentioned in the HPI (Diabetes, hypertension, hyperlipidemia, anemia, carcinoma prostate, carcinoma bladder). I believe only the diabetes is supported based on this documentation. Can you use a dx if it isn't mentioned the status of it? Under the dx of diabetes there were labs ordered and follow-up. The other dx's listed only say "Patient voiced understanding of the instructions." Any suggestions????
    From the gist of the note you've described the pt was seeing this provider for f/u of HTN, lipids and DM. Did the provider happen to give the status of these conditions in the A/P.

    In the DG for 1997 under "Number of dx or Mgmt options it states:

    The number of possible diagnoses and or the number of mgmt options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

    DG: For each encounter an assessment, clinical impression, or diagnosis shouldl be documented. it may be explicitly stated or implied in doucmented decisions regarding management plans and/or further evaluation.

    Were these problems ( htn, lipids) addressed or considered in the providers management options.

    Hope this helps.
    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
    Location
    Harrisburg, PA
    Posts
    14
    Default
    A status of these conditions was not listed. Labs are ordered under the diabetes dx as follows: (Lab: Renal Function
    Hemoglobin A1c
    Lipid Profile & LDL Cholestero
    Ast/Alt
    Thyroid Stimulating Hormone)

    I'm thinking all of these labs are not for the diabetes but the documentation is showing that they are for the diabetes.

  4. #4
    Default
    Quote Originally Posted by adweaver View Post
    A status of these conditions was not listed. Labs are ordered under the diabetes dx as follows: (Lab: Renal Function
    Hemoglobin A1c
    Lipid Profile & LDL Cholestero
    Ast/Alt
    Thyroid Stimulating Hormone)

    I'm thinking all of these labs are not for the diabetes but the documentation is showing that they are for the diabetes.

    The labs you have listed could all be for the dx of DM and especially if the provider has given that information to you and is documented.

    I may need to double check on the TSH but I know for sure that the dx of DM would be based on the NCD policies for those lab test under Highmark Medicare.
    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"

Similar Threads

  1. Radiology diagnosis coding for chronic conditions
    By barber in forum Diagnosis Coding
    Replies: 2
    Last Post: 12-20-2013, 02:28 PM
  2. 3 Chronic conditions..
    By EmilyDingee in forum E/M
    Replies: 1
    Last Post: 05-07-2013, 03:53 PM
  3. MVA diagnosis coding with chronic conditions
    By PeaPod1 in forum Medical Coding General Discussion
    Replies: 7
    Last Post: 01-01-2012, 11:02 AM
  4. chronic conditions
    By raposo1 in forum Cardiology
    Replies: 1
    Last Post: 11-22-2011, 09:21 AM
  5. Chronic Conditions
    By NESmith in forum E/M
    Replies: 8
    Last Post: 07-11-2011, 02:03 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.