Wiki Hypertensive Heart Disease

[heartyoga]

My coder attended a seminar and was told that if patient has had Hypertensive Heart Disease (w or w/o heart failure) that it never goes away and should be in all the subsequent visits' diagnosis and assessment list.

Our EMR puts past dx in the history and lets the provider activate it as needed. Our provider would deem its Hypertension and skip the HHD dx. Our coder comes back insisting that the provider click HHD. Our provider is in the opinion that she could code it from the past med hx.

Who is right?

Thanks.

 

[mitchellde]

The provider must document any diagnosis for each encounter that the coder is coding. If it is not documented on that encounter then it cannot be coded.