Wiki Capturing codes from Physical Exam with no MEAT or support

[jrf0625]

What is opinion on capturing diagnosis codes for risk adjustment coding from the physical exam when there is no Meat or support anywhere else in the medical record? Example Appearance---obese Psychiatric------Depressed Cardiovascular---normal and so on
Should the risk adjustment coders be instructed to code F32.9 from the above without it being mentioned anywhere else in the record, no meds, not in PMH, problem list or assessment and plan.

diagnosis codes, diagnosis coding

 

[Knowlel]

Risk adjustment coding still has to meet (no pun intended) guidelines. The documentation you have provided in your example does not support assignment of the ICD-10-CM diagnosis codes. When in doubt, refer to the ICD-10-CM Official Guidelines for Coding and Reporting - Section IV.

diagnosis codes, diagnosis coding

 

[second to none]

Yes, you still can code those diagnosis from Physical exam like ulcer, depression etc.

diagnosis codes, diagnosis coding

 

[Pathos]

You can code from anywhere in the chart as long as there is MEAT to be found. I consistently find MEAT in the HPI, Exam and some cases even in the infamous Problem List and Past Medical History. However, you need to be careful with the last two. Depending on how the chart was documented can make or break MEAT. Remember that anything that is shown to be an active and current condition can and should stand on it's own proverbial legs.

To answer @jrf0625 post, yes you most definitely can pick up from the Physical Exam, as long as there is MEAT to support the condition. Keep in mind that every chart is different, and must be treated as such when interpreting the guidelines we have.

Hope this helps

diagnosis codes, diagnosis coding