# When to/not code from medical history



## LuckyLily

I will be taking over the ER coding and would like some clarification from fellow ER coders. It has been instructed to me that I should code secondary conditions that are in the Medical History and the patient is taking a medication for this condition to code it. For example, HTN on Lisinopril. This condition is not addressed anywhere else in the encounter. Would this be coded? or should I only code conditions that are actively addressed. 

Thanks for all the help.


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## CodingKing

from the ICD-10-CM guidelines

Section IV.J



> *Code all documented conditions that coexist
> 
> *Code all documented conditions that coexist at the time of the encounter/visit, andrequire or affect patient care treatment or management. Do not code conditions thatwere previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history hasan impact on current care or influences treatment.


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## LuckyLily

Thank you CodingKing but I'm already familiar with that coding guideline.  This is a coexisting condition that is being treated by another physician, but is not addressed by the current ER physician. It is only listed in the Medical History. Additionally, this is a chronic disease, which the guideline says "chronic diseases treated on an ongoing basis may be coded and reported as many times an the patient receives treatment and care for the condition." Does this mean that as long as the patient is taking a medication for a condition, that if patient goes to another doctor and condition is not addressed/treated, but listed in medical history or medication list, that it can still be coded.


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## jimbo1231

*Hypertension*

Having been around ED coding industry a long time, I can tell you that many of the ED coding outfits would code the hypertension partly to give a complete picture of patients risk. Also all information is new to the ED provider. But I would say some documentation noting the hypertension and meds and risk would help.

Jim


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## ens555

*re coding I10 in ED*

I generally code this secondary dx for ED visits.  The blood pressure is usually taken on  adult visits.  So if hypertension is stated in the med hx I pick it up regardless of whether there's a med list.   I also regularly code tobacco dependence or history of such.  These are the two I pick up on almost all ED visits when I have the information.

I find that for level 3 and lower level visits you are often but not always investigating/treating a condition mainly impacting one  body system:  laceration, sprain, simple fracture, OM, rash come to mind.  This is one reason why I don't pick up many secondary dxs for these presenting problems.

Cellulitis can be a level 3 visit or higher.  Here I would add diabetes as a secondary dx as infections in diabetics are taken more seriously.  Hypertension and diabetes are lifelong conditions which can be controlled but not really cured.

If the EDMD is doing PT/INR testing I would look for documentation of long term medications eg Coumadin.  Here I would only code Z79.01 if I have documentation to code the condition for which it's prescribed such as hx of PE or hx of a fib.  

I am lapsing into acronyms so maybe I should stop!  Curious to hear what others have to say.

Eniale


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## exmb

*whento/not code from medical history*



LuckyLily said:


> Thank you CodingKing but I'm already familiar with that coding guideline.  This is a coexisting condition that is being treated by another physician, but is not addressed by the current ER physician. It is only listed in the Medical History. Additionally, this is a chronic disease, which the guideline says "chronic diseases treated on an ongoing basis may be coded and reported as many times an the patient receives treatment and care for the condition." Does this mean that as long as the patient is taking a medication for a condition, that if patient goes to another doctor and condition is not addressed/treated, but listed in medical history or medication list, that it can still be coded.



chronic medical condition being treated by medication would be captured in our facility, per a recent HIA audit of ED.


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## Sarah Ann

LuckyLily said:


> Thank you CodingKing but I'm already familiar with that coding guideline.  This is a coexisting condition that is being treated by another physician, but is not addressed by the current ER physician. It is only listed in the Medical History. Additionally, this is a chronic disease, which the guideline says "chronic diseases treated on an ongoing basis may be coded and reported as many times an the patient receives treatment and care for the condition." Does this mean that as long as the patient is taking a medication for a condition, that if patient goes to another doctor and condition is not addressed/treated, but listed in medical history or medication list, that it can still be coded.



I agree with you 100%- to me just because a pt is on a drug that rolls over from a list doesn't mean they're being treated for it.  The pt is being treated for it by someone else, and it's not even mentioned in the body of the report.  I believe that the physician has to address/assess/manage that's how I see it, I can't assume.  If the condition affects the treatment, I believe that should be conveyed other than from a list that it's updated by they physician of the date of the encounter.  That's how I'm interpreting the guideline.


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## NIKI01

hello, 
I would like to ask for other coders opinion on coding for chronic conditions. For example:
" 27-y/o female with hypertension lupus, HIV hxof C. difficile colitis and recent admission for bacteremia presenting today for bloody stools. final dx. Perianal lesion." there is no provider documentation that he/she reviewed medication list and agree. the list of medication is documented in EMR and reviewed by nurse per nursing documentation. 
I would code only hypertension as can be diet controlled. any opinions? 
thank you so much,
Niki


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## Sarah Ann

Honestly I get that a lot- I was told since the drug list and the disease list show up with the (encounter) note the provider is authenticating the information. Well that's great, but I think it has to be in the narrative. The 3rd of 4th quarter 2019 coding clinic gives an example- of how the physician documents in the note that the patient has I believe they used Crohns disease and they 're taking an immunomodulator. *Because the provider has specifically stated the disease and treatment.*
Based on the guidelines of diseases treated on an ongoing basis- the documentation submitted. Also they stated that ongoing treatment doesn't need to happen at the time of the encounter. In my mind it needs to be in the narrative.
It says the provider specifically states. I personally- just me maybe- would not go to a list of medications- just like I would not go to a list of diseases and look for a "possible match for a medication from a list". I wouldn't use that to verify that the patient is being treated. So if the provider says the patient has this disease and they are being treated with this medication. Then I would code.  Opinions?


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## Sarah Ann

My example- this is more in line of what I feel the documentation should be-
CHF stable-will continue lasix and ACE inhibitor with the same dose-no changes.


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