I can’t remember if I’ve recently covered this topic, so one of us (or maybe both of us) may have Deja vu today. We’re still getting inundated with questions about Problems Addressed regardless of the place or type of service, so whether I’ve already covered this topic or not, it bears addressing it again.
Cheryl, a good NAMAS friend of mine, sent in an actual clip of a note (By the way, I’m certainly happy for anyone to do this, as long as you do as Cheryl did and make sure you redact the patient information). The note states that an emergency room patient presented and is comfortably resting. They have no visible distress; the patient has near resolution of chest pain after the patient had a GI cocktail. It goes on to say in the Impression and Plan that the patient had acute chest pain, and now the patient has acute gastritis. So, Cheryl’s question is, when looking at this episodically, how do we weigh in the chest pain? The patient did present to the emergency room with acute chest pain, and we all know that the minute the patient comes into the emergency room with acute chest pain, we go into “acute chest pain mode.” We also know that on the facility side, when that facility side appending of the code is done, that weighs heavier on the facility side coding, if you’re familiar with that side at all. So that’s going to impact the level of coding on that side.
To answer Cheryl’s question, we need to go back to our “coding 101”. When a patient presents with a symptom, and the symptom is fundamentally diagnosed, then we use the diagnosis over the signs or symptoms. So, if that is true, and that is how we diagnose a condition, the sign or symptom is alleviated, and we actually use the diagnosis, then would use the acute gastritis over the chest pain.
Remember, we also can always go back to the new rules we have about problems that are addressed and what truly is the problem that is addressed for patients. If you look at page 14 in your 2023 revisions of 2021 documentation guidelines, it states, “a problem is addressed or managed when it is evaluated or treated.” I think that’s just a very good catchall for us to always go back to when we’re looking at a note to evaluate if we consider a problem to be addressed in our note. Was this specific problem evaluated and treated?
In Cheryl’s note, my first question is, was it a sign or symptom that was officially diagnosed? My answer is yes. Then looking at the acute gastritis, was it a problem that was evaluated and treated? The answer to that is, of course, yes -that it was the problem that was addressed.
Those two reference points just give us a great place to start and to know those stepping-stones with every note in looking at sign or symptoms, yes or no, problem addressed, was it evaluated or treated -in order to know how to apply those rules.
It does go on further when we’re looking at notes that have conditions that are treated by other providers. In that same paragraph, it talks about notations in the patient’s medical records of problems that are managed by another provider if the provider does address them or manage them. That is kind of our “point and click,” so to say, as to whether we are also going to include those as a problem addressed.
So again, we’re looking to see if they are impacting our providers episode of care, it’s not just enough for our provider to mention them, they actually have to be addressed and actually impacting the episode of care of our provider. They must be considered relevant to their treatment plan and how they’re taking care of their patients.
Don’t just go to the MDM chart. While it is helpful, it’s not the only rule. You really do have to read through the documentation guidelines. I think that’s where we went wrong with 95 and 97. A lot of people relied only on Marshfield guidance and didn’t go to 95 and 97 guidelines like they should have. Don’t forget that the guidelines exist for a reason!
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