Wiki Chronic Conditions

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NESmith

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i don't know if this question has ever been asked and I am sorry if it sounds weird, but I met with one of our providers to discuss his documenttaion of the chronic conditions. He only listed them in the Assessment without giving any information pertaining to the conditions. I told him that he needed to give more information such as; Essential hypertension-Stable on current meds. He told him that the information is in the exam such as; CPOD as a chronic condition and in his exam he states abnormal breath sounds, rales/crackles were heard. I told him that I don't beliieve he can use his exam to support the chronic conditions. Am I correct in telling him this? He stated that he is correct and that I needed to check into this. Please help. Thanks as always
 
My response to him is that the exam section is for documentation of his findings, while the assessment...well it's just that, his conclusion of the patients problems. If from his exam he has findings that a certain chronic condition is unstable, or better, or whatever, that should be reflected in his assessment. As auditors, we cannot assume anything. If the assessment said "DM" only, but the exam said the patient had nerve pain in his hands and feet...should we assume the patient hads dm with neuro manifestations and code it as such? No.
While we can get a feel of how sick the patient is by the documentation, the only way to support the MDM is with a clear picture of what is going on with the dx's.

I am with you that there should be some sort of status with the assessment.

The 95 documentation guidelines say this:

"For a presenting problem with an established diagnosis the record
should reflect whether the problem is: a) improved, well controlled,
resolving or resolved; or, b) inadequately controlled, worsening, or
failing to change as expected."

While he may argue the exam notes will "reflect" this, I would again make the point that he is leaving it up to the auditor to make a conclusion.
 
Please advice on coding the below scenario

Order states Hip right -2View

Technique states : Ap pelvis and frogleg lateral View of hip.

How can it be coded - A) 72170 and 73500
B) 73510

Please advice
 
As a surgeon seeing these patients with multiple diagnoses/comorbidities, how should I list the additional diagnoses in the assessment then?

For example, patient with colon cancer, coronary disease, hypertension, and diabetes sees me for new diagnosis of colon cancer.

How do I know if his diabetes is stable, Type I or II, if he has essential hypertension, etc? How can I comment on stability if it's not my area?
 
In My Opinion if you want to list the chronic conditions because you feel as the surgeon it is important to at the very least state the chronic conditions even thought they were not treated by you, then I suggest you list them and then indicate something like "these conditions are being followed by Dr X."
In this way you can show that you acknowledged the presence of these conditions, however they did not appear to alter the condition you are treating nor the planned treatment of this condition.
Just my suggestion
 
In this way you can show that you acknowledged the presence of these conditions, however they did not appear to alter the condition you are treating nor the planned treatment of this condition.

But they can still increase my level of risk and the complexity of my MDM, correct? For instance, minor or major surgery with or without risk factors.
 
I would count it toward the # of diagnosis due to the fact that you did acknowledge the presence of these conditions and made a conscious decision that they did not warrant additional investigation on your part. If questioned in an audit I would explain in that fashion. Others may not feel the same way, but that is my opinion.
 
Table of risk

colorectal surgeon said:
In this way you can show that you acknowledged the presence of these conditions, however they did not appear to alter the condition you are treating nor the planned treatment of this condition.

But they can still increase my level of risk and the complexity of my MDM, correct? For instance, minor or major surgery with or without risk factors.
Click to expand...

Yes, listing these chronic conditions/co-morbidities will affect the level of risk, if you are recommending surgery. You might even want to title them "CO-Morbidities / Risk Factors for Surgery"

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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