Friday, April 1, 2022

Coding from the Problem List or Past Medical History

Over the last few weeks I have received so many emails from coders with this question, “Is it okay for my team to code for conditions listed in the problem list or past medical history only? If not, why? Can you send me a guideline?”

The answer is NO – Your team should NEVER code for conditions that are listed in the problem list or past medical history only. Why? Per ICD-10 Coding Guidelines, codes should only be assigned for documented conditions that coexist at the time of the encounter/visit, and require or affect patient care, treatment, or management.

Coding professionals should not assign codes based solely on diagnoses noted in the history, problem list and/or a medication list. It is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter.

If the medical record is unclear or ambiguous regarding which condition(s) affected patient care and /or management of the patient, query the provider for clarification.

There is overwhelming evidence to support this practice.  

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