serhaug
Networker
When pulling diagnosis information for risk adjustment from outpatient/physician notes, there is some confusion whether or not to code diagnoses that are listed in PMH. CMS guidance is vague, at best.
Arguments include:
- Code everything listed in the PMH because if the doctor put it in PMH the doctor had to take it into consideration for MDM. (However, that isn't always the case, especially with the new EMRs which autopopulate previous coding data into the PMH).
- Code from PMH only when it is clear the condition played into the MDM on that particular DOS. If it wasn't documented as such, it wasn't done.
- Code nothing from PMH because if it did play into MDM it should also appear in the assessment section.
I'd like to know your individual thoughts and which of the three opinions above most closely matches your coding practice. I appreciate your opinions and feedback! Thanks!
Arguments include:
- Code everything listed in the PMH because if the doctor put it in PMH the doctor had to take it into consideration for MDM. (However, that isn't always the case, especially with the new EMRs which autopopulate previous coding data into the PMH).
- Code from PMH only when it is clear the condition played into the MDM on that particular DOS. If it wasn't documented as such, it wasn't done.
- Code nothing from PMH because if it did play into MDM it should also appear in the assessment section.
I'd like to know your individual thoughts and which of the three opinions above most closely matches your coding practice. I appreciate your opinions and feedback! Thanks!