g hypertension chronic asthma diabetes mellitus COPD and so on for which the

G hypertension chronic asthma diabetes mellitus copd

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Another exception is chronic conditions (e.g., hypertension, chronic asthma, diabetes mellitus, COPD, and so on) for which the patient requires medically management during the inpatient stay (e.g., diagnostic tests, administration of medication by nursing staff, and so on). In the history & physical examinationbelow, you will notice that the patient's brother has been diagnosed with epilepsy. You will also notice that the patient has a history of smoking cigarettes. Assigning codes to family history ofand personal history ofconditions is permitted because they do not impact the DRG assignment (or increase the reimbursement rate).EXAMPLEFAMILY HISTORY OF:The patient receives inpatient treatment for acute bronchitis, and upon review of the patient record the coder notices that there is a family history of lung cancer. Because both conditions are associated with the respiratory system, assigning a code to the family history of lung canceris appropriate (in addition to a code for acute bronchitis, which is sequenced as the principal diagnosis). EXAMPLEPERSONAL HISTORY OF:The patient undergoes inpatient treatment for cerebral aneurysm, and upon review of the patient record the coder notices that the patient has a personal history of traumatic brain injurybecause the patient was in a vehicle accident 10 years ago and sustained a fractured skull, concussion, and brain hemorrhage. Because both conditions are associated with the brain, assigning a code to the personal history of traumatic brain injuryis appropriate (in addition to a code for cerebral aneurysm, which is sequenced as the principal diagnosis). NOTE:Students and new coders often struggle with the decision whether or not to assign codes to family history ofand past history ofconditions. The good news is that even if you mistakenly assign family history ofand personal history ofcodes based on documentation in the patient record, the codes do not impact the reimbursement to the hospital. That means such codes are unlikely to be "counted against" the coder or the hospital as coding errors or fraud/abuse. To be sure, however, when on the job query your coding mentor or supervisor. (See next page for image.)
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