Wiki Chronic Conditions Listed in PMH

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serhaug

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In an outpatient (physician) medical record, when a chronic condition is listed in past medical history (not a problem list) and is not monitored, evaluated, addressed/assessed or treated during that visit (other than the fact it is listed in PMH) can you code that condition?

I'm looking for opinions, please, and any supporting documentation.

Thanks, everyone!

Serine
 
In outpatient coding, when any condition, including a chronic condition, is listed in PMH but is not addressed at all, it is not to be coded. There must be some active treatment.
 
I would have to disagree. If the pt is diabetic or has hypertension, although the physician does not document that he treated that condition, it can have bearing on how he treats the condition the pt came in for. Just for instance, say the pt has hypertension and presents with seasonal allergies. There are certain medications that the doctor cannot prescribe due to possible interference with the management of the hypertension. Most every place I have ever worked required that hypertension, diabetes and certain other conditions be picked up regardless of if that physician specifically treated them in that visit.
 
eadun2000 - if the doctor doesn't document the fact that the condition plays into his MDM for that day, how can you assume it did? Our rule is if the condition was not monitored, evaluated, addressed, assessed, or treated that we do not code the chronic condition in PMH. We coders cannot make assumptions.
 
serhaug said:
eadun2000 - if the doctor doesn't document the fact that the condition plays into his MDM for that day, how can you assume it did? Our rule is if the condition was not monitored, evaluated, addressed, assessed, or treated that we do not code the chronic condition in PMH. We coders cannot make assumptions.
Click to expand...

Please read your coding guidelines located in the front of your ICD-9 book. It clearly states to code all documented conditions that coexist. Hence diabetes, hypertension, etc. I did not write the coding guidelines, I just follow them. From what I understand, it is only chronic conditions like diabetes, hypertension, active cancers, etc. You would not pick up say.. chronic headaches if the pt came in for an ingrown toenail.
 
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eadun2000 said:
Please read your coding guidelines located in the front of your ICD-9 book. It clearly states to code all documented conditions that coexist. Hence diabetes, hypertension, etc. I did not write the coding guidelines, I just follow them. From what I understand, it is only chronic conditions like diabetes, hypertension, active cancers, etc. You would not pick up say.. chronic headaches if the pt came in for an ingrown toenail.
Click to expand...

Actually, the complete sentence reads "Code all documented conditions that coexist at the time of the encounter/visit, AND REQUIRE OR AFFECT patient care treatment or management." How will a coder or any reviewer know whether the condition required or affected patient care or treatment during that encounter if its not documented. How can you make that assumption.
 
I am unsure as to where to find the proof that you're looking for. I'm sorry. I did send another AAPC member, that uses the forums and is always great at supplying the official proof for her answers, a private message to try and get her input into this thread but unfortunately my message hasn't been read... or maybe she didn't feel like replying? Not sure.

I can tell you that, for the company that I work for, we go through validation audits yearly. During these validation audits, they go through our charts and make sure that we are coding per cms guidelines. I can tell you that we have had money taken back because of the lack of chronic conditions being addressed for the time period being audited. The doctors were writing "History of COPD" "History of CHF" etc etc, or they were including the chronic conditions in the PMH portion of the note and they were note showing any current treatment or addressing these chronic conditions in any way. We've been told not to code unless there is documented management of the condition, even if it is chronic. Each note stands alone, this we know. As coders, we are never to assume. When I first started coding, I argued that, as a chronic condition, we know that it is going to be an ongoing DX. I was told by an auditor, "How do you know they haven't had a miraculous recovery?" As stupid as that sounds to me, I don't make the rules... I just follow them.
 
I'm not sure if this is what you're looking for...

Rules for reporting diagnosis codes on the claim are:

-Use the ICD-9-CM code that describes the patient's diagnosis, symptom, complaint, condition or problem. Do not code suspected diagnosis.

-Use the ICD-9-CM code that is chiefly responsible for the item or service provided.
Assign codes to the highest level of specificity. Use the fourth and fifth digits where applicable.

-Code a chronic condition as often as applicable to the patient's treatment.

-Code all documented conditions that coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions that no longer exist.)

http://www.cms.gov/manuals/downloads/clm104c23.pdf
 
I was one of those who received the private message and sorry, I wasn't on the forums this morning, so just read it. I agree with Rebecca - I was going to direct everyone to the Coding Guidelines also.
 
I had initially only sent the message to one person. When I didn't get a response, I went ahead and copied the message and pasted it in a lump message for a few of the most knowledgeable forum users. So if you got the message this morning, that was the second go around since I noticed that this thread was back at the top of the list this morning. The company that I work for allows us VERY limited use of the internet and I'm usually unable to pull up links for people that want "proof".

That being said, thanks so much for your responses. My concern was this; even if a diagnosis is chronic and may affect the treatment of said patient, if the chronic condition is listed ONLY in past medical history with no treatment, monitoring, evaluating, etc etc addressed in the note, do you still code it because it is a chronic condition that COULD very well affect patient care?
I've been told, no, you cannot assume that it holds bearing to patient care/ treatment and if it is written as HISTORY with no documented treatment, assessment, evaluation it must be coded as history.
 
now I need clarification.

Are you saying it is okay to code chronics from the "Chronic Conditions" and/or chronic conditions from the "PMH section" even if not addressed on that particular office note (DOS)?

Thank you
 
so are you saying the CMS guidelines does accept submission of chronic diagnoses when listed in "chronic conditions" and/or "PMH" sections of a note, even if hasn't been addressed for that particular (DOS)? That is is assumed?
 
It is my understanding that "Chronic Conditions" is not the same thing as "PMH", aka PAST MEDICAL HISTORY. A good example of the point I'm trying to get across is this (I'm pulling this example from correspondence pertaining to this subject):

Patient with well-controlled hypertension presents with signs/sx of some type of upper respiratory infection, including wheezing. The hypertension, controlled by XX medication, is noted in the past medical history. Provider determines that patient has asthmatic bronchitis, and prescribes antibiotics and an inhaler. Although the hypertension is not noted again in the assessment, you would code it as a secondary diagnosis, as it definitely affects what type of inhaler is prescribed.

This I totally agree with. Let me explain why. Although the hypertension is included ONLY in the PMH portion of the note, it is addressed. By saying that the hypertension is controlled by said medication, you are addressing the diagnosis, thereby making it a pertinent problem.

Now, if the note does NOT address the hypertension, meaning that Hypertension is written in PMH but no other information is given, I don't believe that hypertension should be coded. Again, let me explain why. How do we know that the hypertension has not gone away? Maybe the patient lost weight and no longer has hypertension, maybe by divine intervention the patient was cured!
 
Past medical history is not exclusively of chronic conditions. But chronic conditions can be a part of the past history.
In your example, though the HTN is a part of the Medical history, the type of previous condition has to be taken into account for treatment point of view for validating a safe drug prescription that do not affect/ aggravate or exacerbate that previous condition.
But a patient with history of hysterectomy comes for pneumonia treatment. Hysterectomy has no bearing in the encounter or its treatment modalities..
At the same time, a patient with aneurysmal clipping done a few years ago,(or even pacemaker), comes for a MRI diagnostic for the emergency department.. Would we give her the diagnostic MRI just because she is well and symptom free for a very long time?. NO, we would not opt for it because it has a great ill effect on the status of having a clip in the vessel. We would opt for CT rather than MRI.
So, doesn’t the past history of a vascular clipping has great bearing over the present encounter.
This is just a tip of an ice-burg and we have very many conditions medical/surgicalwhich have to be addressed to.
Thank you Vanessa. I agree with you
 
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I have been out ill, so I saw the PM this morning. I would not report a diagnosis code from PMH simply because it is PAST...how do you know it is current? Now if it is listed under chronic conditions and affects the treatment of a patient then it could be reported. For example, a patient with DM presents with bronchitis - often prednisone is used, but prednisone will affect the DM so whatever treatment plan the physician decides to follow, the diabetes will have an affect on his/her decision. In a perfect world this train of thought would be clear in the documentation...but since this is not a perfect world (LOL) you can query your physician...
Also, keep in mind that inpatient diagnosis reporting and outpatient diagnosis reporting guidelines are quite a bit different.
This is a good topic of discussion and we will all learn something valuable here!
 
Thanks, everyone, for the feedback. This is exactly the kind of discussion I wanted to get going.

Responding to an earlier post, someone had indicated they don't write the guidelines, they only follow 'em. I, too, try to follow the ICD-9 Coding Guidelines, first and foremost. However, many times they are simply not clear. Ravirro had a good point - how can we ASSUME the PMH played into MDM on that DOS, especially with the EMR's autopopulating every condition the patient has had since the ingrown toenail they had as a fetus inutero?

Lisa makes a good point, too. The inpatient and outpatient reporting guidelines are TONS different. The quote made on page 1 by eadun (although I can't see it right now because I'm typing this response) I believe is for the inpatient guidelines. The guidelines for physician offices are much different.
 
Honestly, this was one of my favorite forum discussions. I'd have loved to have more coders involved to hear more opinions and facts on this topic. Like I said, I even privately messaged a number of members to incite response. Which, I'd like to thank those of you that responded! I agree, serhaug, though the guidelines may be printed in black ink on white paper, it is far from black and white. Much of coding has a grey area. Not to mention that, depending on what insurance carrier you're dealing with, they tend to have their own set of rules sometimes. Thank you, serhaug, as well, for posting such an interesting and relevant subject.
 
I too run into this issue. Pt is here (in the office) for symptoms of a UTI. Then, in the plan/ assessment, the current visit problems are dysuria, urinary frequency, HTN, Hypercholesterolemia, etc. No meds were prescribed during the visit. The HTN and cholesterol dx's appear to be lab related only for the next visit.

I don't think those dx's should be counted towards the overall level of MDM. Other than the BP being taken during the vitals, no mention of either of the chronic conditions in the note, so no way to associate the chronic conditions to the treatment of today's complaint.

any other points of view?
 
Chronic conditions

I disagree that chronic conditions can be reported just because it's noted in the PMH.

Although coding guidelines state, "Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment", The documentation guidelines state, "The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter." Without the provider indicating that the problem is being addressed, as coders we should not assume.
 
eagonoy, the OP is discussing outpatient facility coding, not physician coding. In this case, E&M guidelines do not apply, and you would report all codes related to the patient's medical history, as relevant to the current episode of care.

In the facility setting, chronic conditions are reported for data purposes, as well as to support any adjunct therapy provided while the patient is admitted in the outpatient setting.

We report those conditions stated in all related physician documentation that would/could impact treatment of the current condition. We also include history, if it's relevant to the current care. Experienced coders understand which diagnoses to include, and which can be left off. But to assume you have to code only based on what the provider is currently treating, would be inappropriate in the outpatient setting.
 
Pam - you're correct.. however not every coder is so experience that they can tell right off what can be coded and what can't thus then need for documentation, yes?

"We report those conditions stated in all related physician documentation that would/could impact treatment of the current condition. We also include history, if it's relevant to the current care"

You mean in the entire medical record? what if only the record for the encounter in question is available? that means we need clear documentation, correction?

thank you, !!
 
Depending on the type of outpatient record, there should always be an order, a H&P (a requirement for admission) and the physician note specific to the outpatient service. You may code from all three. You may not code from nursing notes. Other OP services have other documents, and not all OP services are coded based on a physician's note (outpatient labs, for example are coded from the order). If these are not in place, the medical record could be incomplete.

It does take experience, but it also takes an understanding of pathophysiology and disease process so that you can identify the appropriate diagnoses to report.
 
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