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Dx Resolved - this basic question but we have a physician

  1. Question Dx Resolved - this basic question but we have a physician
    Medical Coding Books
    Please excuse this basic question but we have a physician that has started to add "resolved" to his Dx. For example "abdominal pain - resolved". Can we code this or is this like saying "probable"?

    Thanks for your help!

    These are initial ER visits for these HPI. The symptoms have resolved prior to arriving at ER. Sorry for not including this info earlier.

    Thanks!

  2. #2
    Default
    I believe we can't code it if it's resolved, but I"m only about 70% sure of this.

  3. #3
    Location
    Columbus, Ohio
    Posts
    14
    Default
    well he is actually using the word resolved instead of 'history of'. So I do not see a problem coding for it since it is one of the symptoms of the current case?

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    I agree...it is a symptom that the doctor was treating even though it has now resolved, so I think it's appropriate to code it.

  5. #5
    Location
    north seattle wa
    Posts
    103
    Default resolved dx's
    According to CPT- "Do not code any condtions that were previously treated and no longer exist. However, History codes (V10-V19) may be used as secondary codes if the historical condition or family history has in impact on current care or influences treatment"

    If your doc is doing what ours do-
    pt here for follow-up abdominal pain
    dx- abdominal pain resolved
    look at the V67.59- Follow-up exam following other treatment

    We use this one when we have that situation and they aren't treating anything else.

  6. #6
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    We always use the reason they're coming it (abdominal pain)... thankfully, it's resolved. we do the same for sore throats when they come in for a follow up on that too.

    Cottrell - I believe what you quoted is for example: if someone comes in with a sore throat today - two weeks ago they were in with abdominal pain - now resolved - today is being treated for the sore throat (only) - no reason to code the abdominal pain this time - "new" HPI = sore throat...
    Donna, CPC, CPC-H

  7. #7
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    According to ICD-9-CM guidelines: "Signs and symptoms - Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider."

    Abdominal pain is a symptom, so the way I interpret this is that it can still be coded for the follow up visit even if it is resolved.

  8. #8
    Location
    Louisville, KY
    Posts
    1,101
    Default
    Actually, the specific purpose of the follow up would need to be clearly stated in that record.

    Coding symptoms and conditions that have resolved (outside using "history of") is inappropriate and misrepresentative--per the official, government-accepted ICD guidelines.

    Sometimes as coders it's our duty to improve practices that are out of date or questionably compliant. That may involve re-educating our providers or creating a documentation improvement program. It may also involve more creative, but nonetheless compliant ways of dealing with documentation issues.

    In the meantime, I wish everyone luck and encourage them to consider how the payer will review the record and claim against one another. That should help to set policy.

  9. #9
    Location
    Milwaukee WI
    Posts
    4,466
    Default This is for an ER visit
    So I see that P Forster edited the original question to clarify that this is for an initial ER visit, but that pain resolved before patient arrived.

    Is there some other reason patient is in the ER?

    If so, you may not have to code the resolved abdominal pain at all.
    Just because the claim allows for 4 dx codes does not mean you have to have 4 dx codes.

    F Tessa Bartels, CPC

  10. Default
    There is no other reason for the visit. Thanks for helping!

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