rattyvonratkins
New
The subjective diagnosis abstraction part of OP Hospital coding really stumps me sometimes. When a provider puts “history of…” directly in the HPI/assessment (separate from PMH section), do you pick these up as CURRENT diagnoses, or ‘personal history of’ dx codes? I find this very confusing.
Example: Patient is a 32 y.o. male who has been referred by Dr. Smith for seizures and neuralgia. He has a medical history of diabetes mellitus, esophageal varices, pancytopenia, osteoarthritis, scleroderma, chronic fatigue, insomnia, anxiety, depression, and developmental delay.
Do I check if the conditions are also listed under PMH and if they are, code them as 'history of'? Or do I go by the medications they are currently taking to see which ones are being treated? Or maybe I'm thinking too hard about it...
Other times, the providers will mention symptoms that happened previously but are no longer present at the current visit. Would that qualify for History of other specified conditions (Z87.898) dx? As you can tell, I'm relatively new to this!
Thanks in advance for any help you can offer!
Example: Patient is a 32 y.o. male who has been referred by Dr. Smith for seizures and neuralgia. He has a medical history of diabetes mellitus, esophageal varices, pancytopenia, osteoarthritis, scleroderma, chronic fatigue, insomnia, anxiety, depression, and developmental delay.
Do I check if the conditions are also listed under PMH and if they are, code them as 'history of'? Or do I go by the medications they are currently taking to see which ones are being treated? Or maybe I'm thinking too hard about it...
Other times, the providers will mention symptoms that happened previously but are no longer present at the current visit. Would that qualify for History of other specified conditions (Z87.898) dx? As you can tell, I'm relatively new to this!
Thanks in advance for any help you can offer!