Wiki coding PMH on ED patients

[Christi7]

Hello Everyone.

I am looking for clarification on coding PMH on ED patients- I am a CPC, and currently taking the accelerated COC program. While in this program part of my training is to do on the job training. I also want say my present job is to code the professional side of the ED, but during my COC training I am coding the facility side.

I personally do not code the patients PMH unless the provider mentions it in the note or if it has an influence on the patients care at the time of service. Accounts that I have coded during my training get placed on hold, reviewed sent back to me with either an ok to release or corrections needed. with that being said, the majority of the accounts that get sent back I am being asked to code the PMH and medications. I have found several pieces of documentation to further back up my claim why I don't code the PMH and have been told; 1. " I should code what my mentor tell me" 2. "I would rather take guidance from the Coding Clinics themselves, as issued by a collaboration of CMS, AHA, and others, rather than a company that sells interpretations of the guidelines."

I am at the end of my rope and am ready to just drop out of this program and go back to my ED professional coding.

The articulars I included in my emails were from; " ICD10monitor" Erica Remer, MD FACEP, CCDS "coding Chronic Conditions" 1/2018
HCPro "Understand diagnosis coding to protect against auditor scrutiny" 2/19/2009
ICD-9-CM Coding Clinic, Third Quarter 2008 Page: 14 to 15 Effective with discharges: September 19, 2008 – this one is regarding coding medication usage

I would appreciate any advice.

thanks so much.

 

[meghanhannus]

Hello Christi7,

I'm sorry to hear what you are going through. I can't believe the explanation to your question is "code what your mentor tells you" I'm sure if a provider was asking/questioning coding something that would not be their answer.

Not sure if this is the same scenario but when I was doing outpatient coding for the facility the DX coding was different than DX coding for the professional side in that we had to also code the DX of any chronic disease/condition/history of a condition the patient had in addition to the primary DX and reason why patient was receiving treatment. So for example a patient presented for hernia repair the diagnosis coding we would abstract would be the type of hernia as the primary DX and then pull any additional DX code like DMII, HTN, history of cancer(s) etc.... I was told that these diagnosis need to be added to our coding because the diagnosis data for the chronic disease/conditions/histories diagnosis etc... is used informational/quality purposes.

If this is the correct scenario, I hope this somewhat clarifies the importance of also abstracting the chronic conditions and histories.

M.Hannus, CPC, CPMA, CRC