# Coding Situation / Need Feedback Please



## WildAngels25 (Mar 17, 2009)

Scenario:  

Doctor's progress note looks like this: 

Past Medical History:

Hx of DM
PVD
Hx of MI
A-Fib

Active Problems: 

COPD

Assessment: 

Pneumonia
DM type II

What would you code in this scenario?  The doctor's office has reported 486, 250.00 and 412 (and they are trying to say that they think the 496 and 443.9 should go thru as well).  Can they report the anything more than the 486 and 250.00?  I'm saying "no" ... if it's not in the assessment, it's not reportable.  Do you agree?  

Please provide some feedback because I'm getting a lot of flack on this one.  I need some fellow CPC support (and a lil' moral support).  

Thanks!


----------



## dmaec (Mar 17, 2009)

I guess I don't see what difference it 's going to make, unless there are some labs that were done that might not have "covered dx's" unless the other DX's were used.
as for me - I'd code it as follows:
486
250.00
496
427.31

again, I haven't seen the complete documentation - I've no idea what level of E/M they feel they have.. but I don't see an issue either way - with what you feel should be coded "486 / 250.00" or with what they want added. Documentation apparently does support those other dx's.


----------



## lisigirl (Mar 19, 2009)

I'm not sure it would be a problem adding the COPD and Afib dx, because those are chronic conditions, but I believe its more accurate to only bill the diagnoses the MD is dealing with at that encounter.

Of course, the argument could be made that the COPD will be affected by the pneumonia so you're ok coding it as well. Unless lab work is done for the afib, I probably wouldn't add it.

Lisi, CPC


----------



## FTessaBartels (Mar 19, 2009)

*I don't take Dx from History*

I never take a Dx from history (unless I need to use a V code).

I would code the COPD (because MD states it is an active problem), pneumonia and DM type II (both of which are in the assessment).

Just my opinion.

F Tessa Bartels, CPC, CEMC


----------



## lisigirl (Mar 19, 2009)

I just came across an article in DecisionHealth from 3/08 in which Barb Pierce (coding & reimbursement director for Practice Business Consultants) stated that "If chronic conditions aren't addressed and there's no medication adjustment, then I don't list their ICD-9 codes or credit them. If medications are adjusted, I count them."

Barb has been a consultant at our group before. I think she really knows what she's talking about when it comes to E/M coding.

Lisi


----------



## saran2383@gmail.com (Mar 25, 2009)

WildAngels25 said:


> Scenario:
> 
> Doctor's progress note looks like this:
> 
> ...






Hi,

I can understand this document, as per CMS regulation we need to report the diagnosis comes under the Assessment section. We are not reporting the active problem list. If you have any option to suggest that condtion, you use 496 as suggstive diagnosis.427.31 is not a chronic condtion, so don't take in to considaration.

*K.Saravanan.CPC*


----------

