When documenting past medical history for hospital admission, physicals, or progress notes, providers sometimes include both resolved and current conditions. It is important to differentiate between resolved conditions and those that are current and actively treated. Examples of historical or resolved conditions would be previous surgeries or infectious processes, such as pneumonia, that have been treated and are no longer active. Current problem lists should be updated periodically to reclassify any resolved conditions to the past medical history.
Any active disease is identified when it is documented with a corresponding treatment plan even if the disease is stable, the disease is being followed by another provider, or you are only monitoring the disease. Examples may include coronary artery disease, which is being treated with medications such as aspirin and/or nitrates, or HIV followed by an Infectious Disease Specialist.
Review the problem list to confirm that all active conditions are being treated and accurately documented each year.
Nonspecific codes may not accurately reflect a patient’s condition; a common example is congestive heart failure. Many health care providers use the generic code I50.9 for heart failure; however, specific codes exist for different types of heart failure.
The signs and symptoms of various forms of heart failure can be different. Nonspecific codes may not describe the patient and how the disease is affecting their health.
If a cause-and-effect relationship exists between diseases, the provider should document this connection. A clinical example may be peripheral neuropathy, which can manifest as a result of diabetes over time. Diabetes, hypertension, renal failure, congestive heart failure, and coronary artery disease are additional clinical examples that demonstrate this cause-andeffect relationship. How you document the “link” is important. Words such as “in,” “due to,” or “with” identify a link between a primary condition and an established comorbidity. An example of this documentation could be written in several ways: “Diabetes mellitus type 2 with retinopathy,” diabetic retinopathy, retinopathy due to diabetes, or “Retinopathy in diabetes.”
Documenting the linked disease and the manifestations provides greater specificity to the patient’s chronic illness. For example, documented diabetes mellitus type 2 with secondary peripheral neuropathy requires addressing peripheral neuropathy in addition to diabetes type 2. A provider may assess the peripheral neuropathy individually with a separate treatment plan.
When multiple complications exist, providers should document all existing manifestations.
Choosing the correct coding path (selection process) for a diagnosis is very important. The Electronic Medical Record (EMR) or a coder may assign an incorrect diagnosis due to following the wrong coding path. Coders should ensure the code selection appropriately reflects the documented disease.
For example, the incorrect code may be inadvertently selected and coded due to EMR code confusion when following the path for “fibrosis” (cystic) instead of the path for “breast.”
Selecting the correct code path for Fibrocystic Breast Disease includes searching “diffuse cystic mastopathy” (cystic breast, fibrocystic disease of the breast), which is code N60.1. It is important to add additional character for laterality if necessary.
Status codes indicate that a patient is either a carrier of a disease or has the sequelae, or residual effect, of a past disease or condition. Status codes may affect the course of treatment and its outcomes.
Patients have “reminders” of their medical experiences. These reminders are demonstrated by physical “losses” from or “gains,” such as:
Z codes should be used regularly to represent the true picture of the patient’s past health and how that affects them today.
Careful attention should be given to codes that are gender specific. Most of these codes are for conditions relating to the gender-specific organ, and should be reviewed in their entirety before assigning. A common error is the use of a female breast cancer code reported for a male patient. In cases of gender identification change, category F64 codes may be used for status clarification.