# Past Medical History



## chandler80 (Nov 19, 2008)

Is there a list of chronic conditions that is acceptable to code when listed in PFSH/PMH (and often times not mentioned any further in the office note)

Thank you


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## FTessaBartels (Nov 21, 2008)

*Not treated = Not coded*

If the chronic condition is mentioned ONLY in the history and is not being evaluated or treated, then I wouldn't code it.

But perhaps I'm not understanding your question ...

F Tessa Bartels, CPC, CPC-E/M


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## okiesawyers (Nov 22, 2008)

I agree with Tessa.  A chronic condition or any condition for that matter should only be coded if it is addressed and treated in the A/P.  Perhaps I am not understanding your question either.  Let us know if we can help further!


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## katrinabgood (Jan 17, 2009)

I was taught to code chronic conditions such as DM, HTN, and any that might have bearing on what pt is being treated for, such as GERD, COPD, CAD, etc... I have also been told to code all chronic conditions, as it gives "the BIG picture."  Is this wrong?  (I do ER coding in a hospital.)


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## sthibo (Jan 19, 2009)

*Guidelines*

According to the ICD-9-CM Guidelines, Section IV-k, Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. I hope this helps.  You can find a lot of answers to questions in the Guidelines!


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## FTessaBartels (Jan 19, 2009)

*Whose the doctor?*

I did *not* examine the patient. I did *not* take the history. I'm *not* a doctor (or any other healthcare provider). I *don't know *if the DM mentioned in the history has any impact on the broken ankle *unless* the doctor states so in the documentation. 

If it's just in the history section with no further mention, I don't assign a Dx code. 

The provider should document what was done. The coder should code what was documented.

F Tessa Bartels, CPC, CEMC


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## katrinabgood (Jan 19, 2009)

Thanks, sthibo!  That's what I thought, but it certainly wouldn't hurt me to review the guidelines periodically!


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