Wiki PCP using dx from Specialist as part of their PLAN

[JaneFrazier]

Need some input.

A patient comes into the office to see Dr A, who is their PCP. They talk about seeing Dr B who is a urology. In the documentation (in the HPI,) Dr A states that speciality and whatever the doctor is doing (for example, Dr B is doing a cystoscopy for IC) as more of an FYI. In the PLAN, Dr A states the patient is being treated by Dr B for IC and will be followed by Dr B.

Can Dr A use the diagnosis code for IC in his plan to achieve a higher level service? He did not treat or diagnosis the IC. It is more of a FYI or part of the active problems for the patient, but not an active problem that he is actually treating.

I hope this makes sense. Thank you

 

[penguins11]

I would say no, they are not actively treating the problem, nor are they ordering any testing, referring the patient anywhere, etc.

 

[LLovett]

As far as MDM, yes the PCP can count the other conditions even if they are not personally treating them. The PCP still has to take into account the other issues facing a patient. They have to be sure they have weighed all the factors before starting/continuing/discontinuing a therapy, whether it be a prescription or otherwise.

As far as your claim form however, it would not be appropriate to report the diagnosis associated with an issue not being treated by the provider.

Example: Pt has low vitamin D. Pt also is being treated by a dermatologist for a condition that requires the patient to use a med that necessitates staying out of the sun and use sunscreen if exposure is unavoidable. If the PCP doesn't ask/know about the condition and care under management by the derm, he/she could advise the patient to get more sun exposure with out sunscreen to treat the vitamin D issue.

Hope this helps,


Laura, CPC, CPMA, CPC-I, CANPC, CEMC