Wiki Counting additional conditions in the A/P

[Svirgilio]

I feel I need some help regarding whether to give points for conditions listed in the assessment and plan that seem to not be related to the presenting problem. For example: Chief complaint is cough and the A/P has 1. Cough. 2. Diabetes 3. Hypertension. I see this frequently and many times they are adjusting medications and ordering labs and monitoring chronic conditions. Can any points be given for these additional conditions even though they are not listed in the A/P?

 

[MnTwins29]

Since the physician addressed these conditions in the treatment plan, I will count them so long as they are also mentioned somewhere else in the note, such as HPI or ROS. When I think of the "Chief" complaint, I think this: the patient may have more than one complaint or problem during this visit, but that is the MAIN reason they came. In your case, the HTN and DM is there and a current problem, but not the MAIN reason the patient came in - that was the cough. Just because he or she came in because of a cough, it doesn't mean the HTN or DM can't or shouldn't be treated, and if this treatment is documented properly, then the physician should get credit for that work.

 

[Svirgilio]

Thanks for your feedback. I think I will provide some education regarding mentioning these additional problems in the HPI section. I will remind them if they want credit for these additional problems they will have to make some mention of them in the HPI.

 

[Naveen Rachagolla]

Since the physician addressed these conditions in the treatment plan, I will count them so long as they are also mentioned somewhere else in the note, such as HPI or ROS. When I think of the "Chief" complaint, I think this: the patient may have more than one complaint or problem during this visit, but that is the MAIN reason they came. In your case, the HTN and DM is there and a current problem, but not the MAIN reason the patient came in - that was the cough. Just because he or she came in because of a cough, it doesn't mean the HTN or DM can't or shouldn't be treated, and if this treatment is documented properly, then the physician should get credit for that work.

Smith thanks for briefing the treatment plans even though they are not the current problems, but what in case of primary diagnosis in this case, though the reason is cough but the physician is addressing the additional problems which are not reason for visits. what would be the primary diagnosis in this visit ?

 

[MnTwins29]

Smith thanks for briefing the treatment plans even though they are not the current problems, but what in case of primary diagnosis in this case, though the reason is cough but the physician is addressing the additional problems which are not reason for visits. what would be the primary diagnosis in this visit ?

I would need to see the note to make an accurate assessment, but given the information that the cough was addressed and it was the reason the patient came to the office, I would code cough as the first listed/primary diagnosis, followed by HTN and DMII