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more diagnosis listed in plan

  1. #1
    Question more diagnosis listed in plan
    Medical Coding Books
    Our physicians are creating a diagnosis section separate from a plan section. The diagnosis section only contains two or three of the actual diagnosis. The plan section is littered with diagnosis however, it is titled "plan". Can we code from "plan" as well as the diagnosis sections?

    this is an example of what we are seing.

    diagnosis
    chest pain
    copd exacerbation

    plan
    acute copd exacerbation
    severe cough
    lll loss of volume
    -oxygenation stable
    -contin advair
    -prior hx...
    -cont meds
    -d/c med
    UTI
    -levaquin
    Chest Pain 2' cough
    -antitussive...prn
    Hypothyroidsm
    Tachycardia
    -EKG
    Hyperglycemia
    -likely ...

  2. #2
    Default
    anything that they sign is fodder to pick up codes from, if they treated it and documented it and signed it i would probably code it. be sure you are not overcoding and picking up signs and symptoms that are incidental to another diagnosis code.
    Pat A. Trautner, CCS/CPC/CEDC/CHONC

  3. #3
    Smile more diagnosis listed in plan
    Quote Originally Posted by ptrautner View Post
    anything that they sign is fodder to pick up codes from, if they treated it and documented it and signed it i would probably code it. be sure you are not overcoding and picking up signs and symptoms that are incidental to another diagnosis code.
    thank you

  4. #4
    Default
    Quote Originally Posted by tdsmitchell View Post
    Our physicians are creating a diagnosis section separate from a plan section. The diagnosis section only contains two or three of the actual diagnosis. The plan section is littered with diagnosis however, it is titled "plan". Can we code from "plan" as well as the diagnosis sections?

    this is an example of what we are seing.

    diagnosis
    chest pain
    copd exacerbation

    plan
    acute copd exacerbation
    severe cough
    lll loss of volume
    -oxygenation stable
    -contin advair
    -prior hx...
    -cont meds
    -d/c med
    UTI
    -levaquin
    Chest Pain 2' cough
    -antitussive...prn
    Hypothyroidsm
    Tachycardia
    -EKG
    Hyperglycemia
    -likely ...
    I'm assuming you're asking about the Hypothyroidism, Tachycardia, and Hyperglycemia, since the other conditions listed are associated symptoms to the COPD and Chest pain, and wouldn't be coded separately...

    First, you should find out if those diagnoses are confirmed, or if they're differential diagnoses (the word 'likely' by hyperglycemia makes it seem like it's a probable diagnosis, not a definitive one). If they're differential diagnoses, then they add a degree of complexity to the MDM under the #of diagnoses/management options section, but they're not counted as separate 'problems', unless A) they've been confirmed, AND B) they were addressed in the HPI, or in the exam somewhere.

    Doctors can't get credit for listing conditions under the plan that seem to pop up out of nowhere at the end of the note - there needs to be some find of indication as to where they got that information...(How does he know about the tachycardia? Did they complain of palpitations? Did he do an EKG? Did he note a high pulse rate in his exam?) You need to know the whole story of each condition, to count it as its own condition for the E/M level, and the diagnoses must be confirmed, to assign them an ICD-9 code. You should probably confer with the physician, and ask him to make his thought process a little more evident to an outside observer. If you can't figure out what he was trying to say, chances are, an auditor wouldn't be able to either. Hope that helps!

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