I was writing an article for the AAPC Edge and I wanted to make sure I had my facts correct about the importance of the diagnoses in the PMH section of the documentation. So I called my sister in law who is an Emergency Room Trauma physician. I posed this question to her: Do doctors (providers) use medical history (PMH) diagnoses in their decision making when assessing a patient?
She responded that physicians review the PMH to form a foundation of the patient’s medical issues. Then after the examination they can use the PMH to assist with differential diagnoses or to assist in the determination of treatment for that specific encounter.
So, if the chronic and past conditions are used by physicians in the decision making process, wouldn’t that be considered as part of the evaluation of a patient therefore fulfilling the “E” in the MEAT validation concept? I know some coding experts say, “if it isn’t written, it wasn’t done.” At the same time, I can’t see any provider actually writing “I took into consideration the PMH diagnoses in my decision making”. Coding all chronic diagnoses from the PMH provides insurance companies and CMS with a holistic picture of the patient on that specific date of service.
I am not saying coders should be coding all the diagnoses in the PMH as current diagnoses, if they are a “history of” they should be coded and categorized as such, but the chronic conditions that never go away will always have an impact on the decision making of providers, so why not code them?
