choice of Dx for physician practice

I attended recently a coding workshop where we told to use Dx from a problem list even if the Dx is not treated by the physician. The reasoning is that these additional Dx give support to the E/M level. I understand that additional Dx such as DM, CKD, COPD, CHF can complicate medical decision making and certainly raises pt risk level, but I was under the impression that we only code the Dx which our specialist evaluates or treats. I asked our surgeons and they said they do not want to "claim responsibility" or credit for Dx which other physicians treat. Would it be considered "up-coding" to raise the level of service by including additional Dx, which your specialist is aware of (they are listed in the EMR as a problem list), but does not treat?

re: choice of Dx for physician practice

You use the diagnosis responsible for patient encounter that day, as primary. Use additional codes to support management/ Medical decision making that impacts treatment of current "reason for the visit".

re: choice of Dx for physician practice

ICD-9 instructs us to use diagnoses that are the reason for the service, the indication that shows medical necessity. I think if you get out the book and look at the guidelines, you'll find that if the physician also considered underlying conditions in the treatment to code those. For example, if the patient has gall bladder diseases and the A/P says, "Before surgery, will send her to her nephrologist for her CKD" I would code the CKD. If the CKD is only mentioned in the PMH then I have no evidence that the physician considered it today.

Some practices have risk based contracts and coding for all conditions addressed and considered is critical.