Diagnosis in PMH
Is it customary to query for a diagnosis only mentioned in the PMH? For example CHF-for type and acuity. Of course it is obvious that it is chronic if it is only mentioned in the PMH. It will not even be coded if only mentioned as past medical history. Another example is COPD-only mentioned in the PMH. My coding supervisor says not to query if it has no bearing on the current admission, but I think all these chronic diagnosis do have a bearing on a patient's condition even if stable at the time. Please tell me what you think. Thanks.
Martha Stanley, RN, MSN, CCDS
San Juan Reg Med Center
Martha Stanley, RN, MSN, CCDS
San Juan Reg Med Center
Comments
My opinion is that if the condition is being treated as part of the current encounter, for example oral diuretics for the CHF or nebulizers for the COPD, then it should be captured since resources are being used and care is being provided for those conditions.
However if the condition is not being treated, does the condition impacting the providers medical decision making and guiding the treatment of the condition the patient is admitted for? It is always worth a discussion with the provider to ask that question. If the history impacts their medical decision making then they should document that and if not, at least you've had a good discussion with the provider and it may be in their mind for future encounters.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
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"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
However, for something such as CHF, a query to define the type/acuity may impact the coding, ROM, and DRG Assignment.
We should bear in mind that a condition does NOT have to be directly treated with a medication in order to satisfy the UHDDS definition of a secondary condition.
(Example: Pt has 'diet-controlled' Type 2 DM, and does not take medications. The patient is placed on a diabetic diet and his B.S. is monitored in order to ensure his B.S. remains controlled - no meds are given, but the 250.00 is reportable because the DM was monitored.)
AHA Coding Clinic
Sandy Beatty
If the condition is being treated, evaluated, monitoring or increases nursing care you may use as a secondary diagnosis.
Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
Charlene