donaldjr1969
Contributor
Good morning.
I am looking to get some clarification on coding EM notes where a client has three diagnoses yet there is a status update for only one Dx. I do behavioral health coding and I see a lot of notes where a client has, for example, Generalized Anxiety Disorder, Intermittent Explosive Disorder, and Chronic PTSD listed in their note. Yet in the note, there is only a status update for, say, Generalized Anxiety Disorder. The statuses of the other two Dx's are not mentioned.
So here is my question. In the aforementioned situation, I am coding the note as if there is only ONE Dx. My logic is that while there are multiple diagnoses, one status update implies they are only treating one of the active diagnoses. And that is how I will code such a note. I guess I am going by the old adage that if it is not documented, it never happened. Therefore if only one Dx status is referenced, they're only treating one Dx. So in the end, if the client has 3 Dx's but only one status update that is stable, I am coding as 99213.
Is that the proper way to code such a note? For all intents and purposes, the cases I mentioned all meet the criteria of Chronic rather than acute.
I am looking to get some clarification on coding EM notes where a client has three diagnoses yet there is a status update for only one Dx. I do behavioral health coding and I see a lot of notes where a client has, for example, Generalized Anxiety Disorder, Intermittent Explosive Disorder, and Chronic PTSD listed in their note. Yet in the note, there is only a status update for, say, Generalized Anxiety Disorder. The statuses of the other two Dx's are not mentioned.
So here is my question. In the aforementioned situation, I am coding the note as if there is only ONE Dx. My logic is that while there are multiple diagnoses, one status update implies they are only treating one of the active diagnoses. And that is how I will code such a note. I guess I am going by the old adage that if it is not documented, it never happened. Therefore if only one Dx status is referenced, they're only treating one Dx. So in the end, if the client has 3 Dx's but only one status update that is stable, I am coding as 99213.
Is that the proper way to code such a note? For all intents and purposes, the cases I mentioned all meet the criteria of Chronic rather than acute.