Wiki Coding patient reported conditions/conditions from previous records

[warrenfamily103@gmail.com]

Hello everyone,

We recently had a new patient and a lot of diagnoses that were documented did not have a specific treatment plan. For instance, CKD, stage 3 only said "per hx" and to check lab. Based on this, I believe code Z13.89 would be the best code choice because the provider didn't make the diagnosis and isn't currently treating it. Once the patient comes back in to review the lab results and he confirms the diagnosis of CKD, then it can be coded. Would this be correct?

I don't have much to go on by the way of previous physician records prior to the patient coming to our clinic, just a very small problem list from the cardiologist, plus a medical history packet the patient fills out, but I don't believe I can code based on that...
I appreciate any feedback.

 

[thomas7331]

You're correct that the provider needs to confirm that a diagnosis exists at the encounter you're coding in order to assign that diagnosis - you can't code from prior records. But in a case where the provider states that a patient has a history of a particular condition, and you have evidence that the condition still exists - for example, the patient is currently on medications to treat that condition, then some practices will have you code that. Also, if you have evidence from prior records that a particular disease may still be present at the encounter you're coding, you can use that information to submit a query to the physician for clarification as to whether or not to code it.

In your example, I would not code Z13.89 for a screening. The provider has indicated that there is something in history that warrants the test they are ordering and that would not be a screening, which is a test done for a healthy and asymptomatic patient for early detection purposes. If you need clarification on the reason that lab test was ordered, then I would query the provider and not assume it is a screening.