Wiki coding chronics

[pamtienter]

Chronics in the clinic

In the clinic setting, you would code chronics that were addressed that day as some part of the reason they were in. If they have a chronic condition, such as diabetes, and they are on meds for it, AND that comes into play with the reason they are in, then it can be coded IF it is documented that way. I wouldn't code the diabetes, for example, if they were in for sinusitis and they just listed their diabetes med in the med list with no other reference of it anywhere else in that visit's documentation. But if they said their illness was affecting their diabetes and they took into consideration their diabetes med or blood sugars when prescribing a med for the illness, then I would. They would need to document that chronic illness in their assessment and/or plan.

I'm not sure how it works in the outpatient world, but if the patient is coming in for a colonoscopy and they assess the chronic conditions and note they are stable on the current meds, I would think then they would be coded.

 

[pamtienter]

I would not in the clinic, no.

 

[Anna Weaver]

If the patient is receiving anesthesia, we code the chronic conditions if the anesthesiologist lists them. They can cause a problem sometimes and they select their patient status modifier by the patient diagnoses and the difficulty needed for the patient.

So, to answer, it just depends. I think you will find as many coders who do as you do those that do not code chronics consistently.

If the patient is here for an office visit and no treatment is done for a chronic problem, say they are here for OM and they also have hypothyroid and nothing is done for the chronic problem, I code the OM. If however, they are here for their annual and the Dr. lists their medications, treatments, etc. I code it all.

If the patient is having surgery, I code the DX for surgery, and anything the anesthesiologist lists also as these are contributing or comorbidities.

If the patient is having conscious sedation and the Dr. doesn't list all the other dx, neither do I. So, if they are here for colonoscopy and the physician says they are having abdominal pain and rectal bleeding and the colonoscopy didn't find anything, I would code the abdominal pain and rectal bleeding. The Dr. will list anything that he feels will contribute to the difficulty of the procedure. Then I would code it.

Does this make sense?

 

[Anna Weaver]

chronics

Where does it need to be listed in order to consider it relevant to the procedure? The chronics are usually just listed on the H&P under past medical history and I was told to code them if they are on a current med.

If anesthesia used, there should be a separate sheet/report and they list the history there. If not a separate sheet, the H & P should list, but I usually check through anything the Dr signs to see if they have added anything. Like in progress notes etc. Depends on what kind of record, who fills it out etc. There are just some chronics that you know could interfere or cause difficulty to the patient. I always watch for hypertension, diabetes, GERD, COPD etc.
Some of the diagnoses will not necessarily interfere with the surgery, but the surgery and anesthesia may interfere with the disease, if this makes sense. Some medications/anesthesia will cause blood sugar to raise causing complications in a diabetic patient. Some with hypertension have to be watched closely. Sometimes people with GERD have more problems with anesthesia than others. Those with COPD may require breathing treatments after surgery. There's just a lot to watch for so chronic conditions are really important where surgeries/procedures requiring anesthesia are concerned.