Wiki Coding Final Diagnosis - From PMFSH

[jemimah crescentia]

Hi All:

Can anyone help me to know whether there is any available guidelines instructing us that "all the conditions documented in the past medical history of the patient had to be coded in the final diagnosis or not" for an outpatient visit, I am working for outpatient facility and using evaluation and management codes, really confused and need help

Thanks in advance for any assistance,
Dr.Jemimah Crescentia, CPC, CPMA

 

[m.j.kummer]

Hi All:

Can anyone help me to know whether there is any available guidelines instructing us that "all the conditions documented in the past medical history of the patient had to be coded in the final diagnosis or not" for an outpatient visit, I am working for outpatient facility and using evaluation and management codes, really confused and need help

Thanks in advance for any assistance,
Dr.Jemimah Crescentia, CPC, CPMA

Coders can?t assume the past medical history diagnosis has a current effect on the current condition for which the patient is receiving treatment. Unless the physician directly states that the past medical condition has a direct link on the treatment for the current encounter, coders should not code the past medical history conditions.

According to ICD-9-CM Official Guidelines for Coding and Reporting; Personal history codes (V codes) explain a patient?s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.? ? ?History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.?

If past medical history is to be reported, unless there is a direct physician statement that the past medical condition has a direct link on the treatment for the current encounter, only the personal history (V codes) should be reported and not a code for reporting the condition as current.

 

[jemimah crescentia]

Thanks a lot for your reply and detailed explanations kummer,

It will be of great help if you could forward me the link pertaining to this guidelines,

With Regards,
Dr.Jemimah, CPC, CPMA

 

[BenCrocker]

Don't you have an ICD-9-CM sitting somewhere in the office?