Wiki Coding from History

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Ravirro

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Hello fellow coders.
I am interested in finding out what your take is on "coding from history." We have a vendor that routinely pulls codes from PMH or HPI that are not being Monitored, Evaluated, Assessed or Treated (nothing shown as such in documentation). As you are all aware, our job is to make sure our submissions to CMS are accurate and truthful. Is it okay to allow submission of codes form history for extra money? Or maybe I am being over cautious. What should i be "aware of" or what should i consider before excluding diagnosis codes documented in history (even if not addressed or documented as having any affect on current condition being treated). Your opinion and feedback is greatly appreciated.

Thank you.
 
You should only be coding problems the provider is addressing.
Ex:
Pt came in with a cough. The provider list PMHx as history of htn and prostate ca, but in the A&P the provider is only addressing the cough and treating it with medicine. The htn and prostate ca should not be used; however if they had found that during the Physical Exam that the patient's blood pressure was high and decided to adjust the htn meds then you could use htn

To my knowledge you should not be using the PMHx dx's to upcode. This could cause big issues. The problem needs to be addressed whether monitoring it, ordering labs, etc.

Hope this helps
 
I agree, only if a condition is managed controlled or treated or if it is a co morbid condition. using the above example if inaddition to everything stated the patient was noted as being HIV positive status. Then even if not treated we should code this with the cough.
I am uncertain though how the vendor in question sees pulling dx in the history will increase the reimbursement??
 
Could be that they are pulling extra diagnosis codes to increase the MDM; which could be the difference of a (i.e.) 99213 versus 99214...assuming the other components are there. I agree with the previous posts. This is adding "fluff" and doesn't qualify medical necessity...in my opinion.
 
Thank you for your in put and the terrific example. This is the validation I needed. The vendor requests records from providers and reviews for additional chronic conditions (HCC) to submit to CMS. My fellow coders have cautioned that this is inappropiate but you know money talks nowadays. We will continue to be vocal and caution against such type of submissions for additional dollars.:)
 
I recently attended a meeting on hierarchical condition categories. I have some information you might find useful. Once I locate it, would you like a copy?
 
Rebecca,
I'd like a copy of the HCC info too please. I'll send you a message. Thanks!
 
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