The Problem with Problem Lists
We get wanted to share a common question we get in from coders within our community about using the problem list. Is using the problem list to support coding a secondary diagnosis allowed?
Problem lists can be a problem because often they are not updated, and some conditions listed on the problem list have long ago been resolved and are no longer active.
Every patient encounter must stand on its own. Anesthesia providers assess the patient’s current physical status during the anesthesia assessment. The American Society of Anesthesiologists (ASA) ranking of the patient physical status contains six levels to distinguish between various levels of complexity of the anesthesia service provided. The purpose of the system is to assess and communicate a patient’s pre-anesthesia medical co-morbidities.
The definition of each level (P1-P6) and examples are outlined in the ASA Relative Value Guide (RVG). Assigning a physical status classification level is a clinical decision based on multiple factors made on the day of anesthesia care by the evaluating provider. What is important is to demonstrate in the documentation the co-morbidity or diagnosis that is supporting the level. Just because a condition appears in a problem list does not mean that the provider considered that to be contributing to the assignment of the level. Care must be taken to ensure whether acute or chronic conditions really should be reported on the claim. Only those conditions that are recorded and supported by the provider’s documentation should be coded.
Coding professionals need to uphold the integrity of each claim by ensuring that claims are supported by the documentation that occurred at the time of the patient’s encounter.
ACE is here to help with any coding questions you may have!
Susan West, RHIT