Wiki Using problem list diagnosis's

[sroyal1031]

I am coding for a FQHC clinic and am just starting my coding career. I am new to looking at E&M visit documentation. I am wondering if I can code from the problem list on the report if no where else on the report has the condition documented and that condition is currently being treated.

Thank you

 

[AmandaBriggs]

It's not typically advised to code from the problem list as the visit may not be pertinent to all of the problems listed in the problem list. I recommend reviewing Section IV of the Official ICD-10CM guidelines. I find the acronym MEAT to help when deciding what diagnosis codes to assign. Did the provider Monitor, Evaluate, Assess, and/or Treat the problem. Another helpful acronym is TAMPER - Treat, Assess, Manage, Prescribe, Evaluate, and/or Refer.

 

[sroyal1031]

It's not typically advised to code from the problem list as the visit may not be pertinent to all of the problems listed in the problem list. I recommend reviewing Section IV of the Official ICD-10CM guidelines. I find the acronym MEAT to help when deciding what diagnosis codes to assign. Did the provider Monitor, Evaluate, Assess, and/or Treat the problem. Another helpful acronym is TAMPER - Treat, Assess, Manage, Prescribe, Evaluate, and/or Refer.

Thank you for your response, I am starting to familiarize myself with the acronym MEAT.