Wiki Diagnoses not mentioned

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Radcoder86

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Hi, I was wondering if diagnoses can be included in an encounter even if they're not mentioned. I was always under the impression we couldn't, but was recently at a meeting and thought the speaker said we could because anything the doctor is taking into account works towards the E/M level, but you just want to make sure they're the last diagnoses used. Am I understanding that correctly? The doctors in my office very often put down diagnosis codes when the patient was not seen for those issues, but they are chronic diagnoses that probably play a part in the doctor's decision making.

Thanks!
 
you are only to code out diagnoses that the provider rendered care for on any given date of service or diagnosis that relate/hinder/help a condition. I.E. pt seen for a foot ulcer. Pt has diabetes. You would code the ulcer by stage then 2ndary you would go the appropriate DM code. This rule is listed in the guidelines in the ICD 9 book. To bill out dx codes that the pt was not treated for is fraud and allows the provider to have a higher E/M level which is not compliant.
 
The guidelines say to code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. These diagnoses the doctors are putting on the visits aren't to increase the E/M level being billed, they're still determining the level by the chief complaint the patient was seen for, but if they have to take into consideration how a patient's chronic conditions and medications will effect the treatment of what they're being seen for, then is it okay to put those down? That's what my understanding was from the lady that spoke at the meeting.
 
you only code conditions that your provider is treating the patient for or that affects another condition like was mentioned above. If a patient has prostate cancer, but is receiving care for this from his oncologist only, your provider would not bill out this dx.
I worked for a cardiology group that would list at least 8 dx codes for each pt, most not related to the care that the cardio was giving. It is true that the # of dx codes listed can play into MDM. Look at your book- under "number of dx or treatment options"; if a dr lists 4 dx codes but is truly only treating 2 dx, then that affects the MDM in a false way.
 
Thanks, Teresa! I'm a new coder and there are some things that can be so confusing and sometimes there is a lot of conflicting information out there. :rolleyes:
 
I think there are 2 separate issues being combined here.

A provider does not have to treat a dx in order to get credit for it under MDM. They would however need to document it in their note in order to get credit for the decision making work done in relation to it.

The dx reported on the claim form should only be the dx treated by the provider at the visit.

So you could have an assessment and plan with 5 different dx, 3 the provider is managing and 2 that others are managing but are considered in the MDM process of the provider. The provider would get Dx points for all 5 but the claim form should only reflect the 3 that they are actually managing.

On the flip side, if a patient has a chronic issue that affects management but the provider doesn't document it, they would not get credit in either MDM or report it on the claim form. Each professional service must stand alone, the fact the patient has a history doesn't count for anything unless appropriately documented for the date of service in question.

I hope this helps,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
 
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