Q&A Office visit coding

[LauraGayle]

54 yo with diet controlled DMII s/p sleeve gastrectomy 3.5 yrs ago on no meds since bariatric surgery. Takes vitamins only. DMII x9 yrs. Prior to Surg took Avandaryl, low dose Lisinopril 10mg for kidney support. After 135 lb et loss, blood pressure post bariatric surg 100/60- 120/70 at routine PCP visits. Prior to bariatric surg bp 130/80-120/80. Never rx any BP meds. At most recent PCP visit Bp 110/66 and previous 100/60. PCP codes 250.00 and 401.1.. When questioned PCP why she coded 401.1, she said because she is "monitoring" the diabetic patient for hypertension ( though not symptomatic ). Is it appropriate to code for hypertension without symptoms and on no treatment for hypertension just because the patient has controlled DMII? ( per med record no elevated BP x 3-4 yrs). Could it be that DMII with HTN gets higher reimbursement than just controlled DM? Can you code for a dx if you are "monitoring" for it as is a risk factor (heart disease) with (controlled) DMII?

 

[Laureen]

In the outpatient/physician world we don't code conditions unless the patient definitely has them i.e.. no rule outs so I agree with you that this is not correct. It's totally appropriate of course to screen for suspected conditions but I would not it on the claim form. There are codes in the ICD manual for "suspected" conditions not found i.e. V89 category.

And if I was the patient and saw that (and have) I tell them to correct my record because I have been denied insurance because of it. They thought I may have MS and did a bunch of tests and turned out I had complicated migraines that were causing my one sided weakness/numbness and vision issues. But one of the offices coded me as actually having MS.

 

[LauraGayle]

In the outpatient/physician world we don't code conditions unless the patient definitely has them i.e.. no rule outs so I agree with you that this is not correct. It's totally appropriate of course to screen for suspected conditions but I would not it on the claim form. There are codes in the ICD manual for "suspected" conditions not found i.e. V89 category.

And if I was the patient and saw that (and have) I tell them to correct my record because I have been denied insurance because of it. They thought I may have MS and did a bunch of tests and turned out I had complicated migraines that were causing my one sided weakness/numbness and vision issues. But one of the offices coded me as actually having MS.

 

[LauraGayle]

Thank you so much, Laureen. You noted, "It's totally appropriate of course to screen for suspected conditions but I would not it on the claim form.". To clarify my understanding, you would not note the 401.1 on the claim form ( adjust monitoring for htn) but a V code would be more appropriate? And then, how does one go about getting the 401.1 deleted from the medical record. I have heard it is quite difficult, but do not know where to begin; especially since the provider it adamant that she is appropriate to document the 401.1? Where do I go from here? The patient is also looking for insurance, but now afraid to until this issue is resolved.

 

[Laureen]

Yes sorry - I'm saying I would not code the patient as 401.1 unless they are definitely diagnosed as having HTN. As far as removing from record I did that as a patient by writing letters to my physician's office and having then send a letter to the insurance company I was seeking life insurance from. I had to be a real pest to get it done.

Do you work for the physician that is doing this or are you advocating for a patient?

 

[LauraGayle]

I am advocating for the patient. The patient has never been told she had htn nor treated for it. She was on daily 10 mg low dose lisinopril for kidney support as standard of care for DM II. On absolutely no meds since bariatric surg 3.5 yrs ago. The patient is anticipating a fight to have this reconciled as the PCP is adamant she is appropriate. Where does she go after PCP will not cooperate?

 

[Laureen]

I really don't know how to advise you. I'd ask to at least get a letter from the physician stating that the patient does not have hypertension but that the lisinopril was prescribed for the diabetic nephropathy. But honestly the high blood pressure diagnoses isn't going to hurt her as compared to her true diagnoses. s/p gastric bypass and diabetes are what potential life insurance reviews will focus on. This is all just my personal opinion - please consider accordingly.