Wiki History of Diagnosis (MM) for FBSE

[arozance27]

Per the updated 2021 AMA E/M guidelines, would a History of Diagnosis (ex: MM) for FBSE no longer support an E/M level on its own?

Our EMR vendor has their coding setup such that this doesn't generate an E/M code in the billing software.

Thanks!

 

[thomas7331]

Per the updated 2021 AMA E/M guidelines, would a History of Diagnosis (ex: MM) for FBSE no longer support an E/M level on its own?

Our EMR vendor has their coding setup such that this doesn't generate an E/M code in the billing software.

Thanks!

I have not seen anything in the new guidelines that would indicate that history would not be a factor that supports an E&M level.

However, this wouldn't really be the appropriate primary diagnosis for the encounter you're describing here - I would recommend Z08 as the primary diagnosis in this situation with the history diagnosis as secondary. Per guidelines, a personal history of malignancy requires that Z08 be coded first and your software may be picking up this error. Z08 includes medical surveillance following completed treatment for neoplasm and this more accurately describes the primary reason for the encounter.

 

[Sarahp941]

Our vender also states, from the AMA classification, with the new 2021 ICD 10 codes for "history of", will not generate an EM code as there is no care to provide. You must document a scar and then add your "history of" dx to generate an EM code. I am curious as to where we can find documents that classify the "status" of a dx. For example: AKs are considered a minor condition. Our Providers are stating that AKs should be chronic since you are dealing with a condition that could easily morph. So now I have a Provider point of view versus a vendor. I cannot find any documents that support the status level of a diagnosis. Any thoughts would be great! Thanks
***I wanted to edit my question. I understand the diagnosis status is indicated within the AMA Guidelines but they are not tied to a specific dx entirely.

 

[thomas7331]

Our vender also states, from the AMA classification, with the new 2021 ICD 10 codes for "history of", will not generate an EM code as there is no care to provide. You must document a scar and then add your "history of" dx to generate an EM code. I am curious as to where we can find documents that classify the "status" of a dx. For example: AKs are considered a minor condition. Our Providers are stating that AKs should be chronic since you are dealing with a condition that could easily morph. So now I have a Provider point of view versus a vendor. I cannot find any documents that support the status level of a diagnosis. Any thoughts would be great! Thanks
***I wanted to edit my question. I understand the diagnosis status is indicated within the AMA Guidelines but they are not tied to a specific dx entirely.

I'm not sure what you mean by 'status' here or in what context you're using this. As far as assignment of CPT codes or EM levels, these should never be driven strictly by ICD-10 code choices but rather by documentation, and any attempts to program this into a software is invariably going to result in some incorrect coding - EHR systems that try to automate the process of selecting codes this way are notoriously flawed in this respect. Regardless of what your software vendor tells you, they should have NO say in the selection of diagnosis or the appropriate assignment of codes. They can advise you on how their systems works and help you to find workarounds or add programming updates if you or your providers find that it is not working correctly for you in your coding or billing process, but their role is not to dictate how your practice's encounters are coded.

 

[CODE.REBECCA.DEWICK]

Our vender also states, from the AMA classification, with the new 2021 ICD 10 codes for "history of", will not generate an EM code as there is no care to provide. You must document a scar and then add your "history of" dx to generate an EM code. I am curious as to where we can find documents that classify the "status" of a dx. For example: AKs are considered a minor condition. Our Providers are stating that AKs should be chronic since you are dealing with a condition that could easily morph. So now I have a Provider point of view versus a vendor. I cannot find any documents that support the status level of a diagnosis. Any thoughts would be great! Thanks
***I wanted to edit my question. I understand the diagnosis status is indicated within the AMA Guidelines but they are not tied to a specific dx entirely.

My provider also says AK's are chronic. im really looking forward to seeing more info....