Wiki When too many DX's are enought

[david.feliu910]

Hey I wanted to ask a two part question one consisting the appropriate coding of Dx's for ED visits, and the controlled substances requirements for medical decision making.

I have found myself when coding ED charts that patients would come in with a history of chronic illnesses sometimes not even pertaining to the initial reason for the visit. I know the coding the reason for the initial visit is imperative as well as any history. However,chronic illnesses that do not pertain to the visit, are no party of the history should they be included as well? When are too any Dx's codes enough?


Lastly i want to inquire if there was a list or a standard for what was considered a control substance when considering a high risk for the medical decision making for coding and e/m code. I am relatively knew to this and any advice or guidance would be greatly appreciated

 

[BenCrocker]

Past history should only be coded WHEN the historical information is related to the diagnosis. Example: Some one comes in complaining of shortness of breath. History of thyroid issues. Unless the thyroid has something to do with the breathing it should not be coded. However I do remember learning somewhere that if the doctor checks the thyroid during this encounter it then applies as well but the Breathing, in this case is primary Dx.

Also, as my preparatory teacher taught us, you have to code as if you're telling a story of the encounter.