# coding from medication list



## akandrew (Sep 28, 2009)

I work for a vendor who does Medicare risk adjustment.  The coders were informed recently by the director of the company that we are to start coding from PMH and the medications list.  For example: if we see chronic conditions listed in the PMH and we can identify that they taking medication from the medication list, we can code that condition.  I have never been trained to code that way and I am having a hard time complying with the company's wishes.  I am trying to find some documentation pertaining to this type of coding to show one way or the other that it is or is not proper documentation coding.  I believe that the medical record should have specific language from the provider that the patient is being treated for a chronic condition such as saying: "patient has a history of a-fib treated with coumadin" instead of seeing a-fib in the PMH and coumadin in the medication list and matching them up.  We are told to code this way if the patient is being seen for a completely different condition.  I need some feedback on this or some direction to documentation guidelines.  I explained to her that we are not nurses and I am uncomfortable coding this way.  I have reveiwed the ICD-9CM Official Guidelines for Coding and Reporting several times to see if there was any reference to medication lists and PMH.  The only item I found close to my dilemma is in the Outpatient Guidelines, K. (Code all documentated conditions that coexist).


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## RebeccaWoodward* (Sep 28, 2009)

What was their reference?


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## akandrew (Sep 28, 2009)

Hi Rebecca,

There was not a reference.  The Director is a nurse and said that we should be able to code chronic condiitons based on the medications they are taking from the medication list and match them to the PMH list.  She says it shows active treatment and therefore should be coded.  Do you have any referene material?

thank you,
Arlene


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## Lisa Bledsoe (Sep 29, 2009)

*Difference*

Just my two cents, but I did risk adjustment coding a couple of years ago.  I believe what you are doing is reviewing the past 2 years of the record?  The company I worked for did the same - if it said afib in chronic conditions we counted it.  It's not really that you are "coding" it, but listing the chronic conditions that count toward risk adjustment.  I don't completely understand it, but risk adjustment coding is different than coding for a claim.  I hope that helps.


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## mitchellde (Sep 29, 2009)

Good point Lisa, she is right and it makes perfect sense if you are doing risk adjustment.


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## RebeccaWoodward* (Sep 29, 2009)

"It is the physician’s responsibility to ensure that documentation reflects the services furnished and that the codes selected reflect those services."

"To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or already established. The physician then uses the presenting illness as a guiding factor and his or her clinical judgment about the patient’s condition to determine the extent of key elements of service to be performed. The key elements of service are: History,Examination, medical decision making."

http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp


*Quote:* "For example: if we see chronic conditions listed in the PMH and we can identify that they taking medication from the medication list, we can code that condition."

The issue I have with this is what if the "CC" is completely unrelated to the PMH?  Coding those conditions could influence your MDM which would not be accurate if those conditions weren't pertinent to the visit.

Any other views?


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## RebeccaWoodward* (Sep 29, 2009)

I was typing this when you guys replied.  Ok...that does make sense.  See...I wasn't thinking "outside of the box"...  Good information.


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## akandrew (Sep 29, 2009)

Thank you ladies for your input.  I feel better now about doing my job.  This was my first time using the forum and it really does work!  Have a great day!

Arlene


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