Wiki listing dx

[melissalynnfalkowski]

Having a huge problem with payers telling my providers to list all pt dx on claim even if they are not treating that day they tell them the dx must be involved in MDM so list them (although its just dx listed) no A/POC

Auditing seminars have told me that unless you are treating it and it directly effects their POC it should only be listed in the PMH and problem list.

Thoughts? references?

 

[MnTwins29]

From E/M university

"E/M University Coding Tip: Problems which are not being addressed specifically by the physician during the encounter may still be counted if they significantly increase the complexity of the cognitive labor required. For example, consider a patient with diabetes who is being evaluated by a vascular surgeon for a lower extremity revascularization procedure. It would be appropriate for the surgeon to include diabetes as an ?established problem, stable? when calculating the problem points. This is because the comorbidity of diabetes does significantly influence the risk of the procedure and the complexity of the post operative management." (Bold font added by me)

 

[Saedron]

"E/M University Coding Tip: Problems which are not being addressed specifically by the physician during the encounter may still be counted if they significantly increase the complexity of the cognitive labor required. For example, consider a patient with diabetes who is being evaluated by a vascular surgeon for a lower extremity revascularization procedure. It would be appropriate for the surgeon to include diabetes as an ?established problem, stable? when calculating the problem points. This is because the comorbidity of diabetes does significantly influence the risk of the procedure and the complexity of the post operative management." (Bold font added by me)

But if the surgeon was seeing the patient for the first time, it would NOT be established problem, stable. It would be NEW problem, stable. That would ramp up the code because the problem is new to the surgeon even if it's not new to the patient.