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Tag Archives: Associated

Symptoms associated with disease process

Posted on by
Hello,
If patient has anxiety and depression and is on medication for both, and provider is also managing patients sleep disturbance with another med, can I report a code for sleep disturbance? I know the guidelines say not to code for symptoms routinely associated with a condition but since it’s being managed separately can I report the code for sleep disturbance in addition to depression & anxiety?

Medical Billing and Coding Forum

HPI: Associated signs

Posted on by
Hello to All and thank you in advance for your help!
I am struggling to understand why I cannot use patient’s ‘No" response to Associated signs to count it as an element for HPI. An example could be: patient’s Office visit for hemorrhoids. I have location, duration, quality; I just need one more element to count total 4 for HPI. I have 10 ROS and I have 3 PFSH. In HPI patient states ‘no bleeding, no nausea, no constipation." May I count pt’s denial to Associated signs as an element? I believe the doctor did his diligence by asking and pt replied; it just happened to be a negative response to Associated signs.
What is the rational here?
Thank you.

Medical Billing and Coding Forum

Coding BMI without associated DX

Posted on by
Hello, I need some clarification, if you will on something. As it pertains to Risk Adjustment Coding, is the coder allowed to extract just the BMI code if documented, without any associated dx also being documented, such as obesity, morbid obesity, overweight? I understand that the BMI codes are secondary codes only so they cannot be primary dx codes, but as far as reporting for risk can the BMI code be reported alone if the provider did not document anything pertaining to the patient’s weight?

Medical Billing and Coding Forum

BMI & Associated Condition

Posted on by
Hi,

To report BMI codes we should have evidence of associated diagnosis (Such as obesity,Morbid obesity,obese).

My question is Apart from these conditions (obesity,Morbid obesity,obese), any other supporting disease conditions are there?

Can we consider OSA (Obstructive sleep apnea) along with CPAP treatments as associated condition/evaluation (Supportive evidence) for BMI (more than 40).

Thanks and regards,
Dhanesh M

Medical Billing and Coding Forum

Reducing Risk Associated with Anesthesia

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By Jeremy Wale, JD, ProAssurance Risk Resource Advisor Nearly every hospital in the United States provides anesthesia services to patients. Most offer surgical services with general anesthesia, providing for safe operative care of patients. Such services bring risk exposures, many of which you can proactively mitigate. General anesthesia demands a patient’s airway be protected, and […]
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