Clean up your problem lists to facilitate accurate coding
Brian Murphy
I enhance and elevate careers of mid-revenue cycle healthcare professionals. Published author, podcast host. Former ACDIS Director.
Per CMS, a problem list is “a list of current and active diagnoses as well as past diagnoses relevant to the current care of the patient.”
But they’re often much more.
Physicians use them as a place to think in ink about ongoing and active conditions or store other summarized patient data.
I like to think of problem lists as a scratch pad or a rough draft; a place for providers to creatively brainstorm about their patients, an interesting place to review as a source of ideas.
Not ready for publication.
This also seems to be the case when it comes to coding from the problem list. Problem lists are often poorly maintained and sporadically updated (and undated), which makes coding from them a compliance risk.?
Finding definitive guidance on compliant use of this important tool is difficult, but I did some research to shed some light on the issue.
Here’s what I found.
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What the guidance says
Unfortunately, the ICD-10-CM Official Guidelines for Coding and Reporting contain no guidance about using the problem list as a source of coding, so our most definitive reference is out.
However, Coding Clinic mentions the problem list and one of the more recent and helpful entries, Third Quarter, 2021, pp. 32-33, states the following:
“Coding professionals should not assign codes based solely on diagnoses noted in the history, problem list and/or a medication list. It is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter."
The next place to turn is CMS, where information regarding problem lists is disappointingly thin. Rose Dunn has a good article on this topic as it relates to HCC coding over on the blog of Libman Education, in which she refers readers to a helpful 2008 CMS Q&A (see link below). From that piece:
I often refer my clients to the “Risk Adjustment User Group Questions & Answers” published by CMS. While originally answered in 2008, the instruction has not changed. The question of coding from problem lists is discussed:
Q: Is an undated/unsigned problem list acceptable documentation of a diagnosis if the progress notes refer to the list in the medical record?
A: Plans should use the progress notes as documentation to support the diagnosis instead of the problem list. Problem lists can include any and every type of condition for a person regardless of whether the beneficiary received services for the conditions during the data collection period, and?are not acceptable stand-alone documentation.
The CMS Risk Adjustment Data Validation Medical Record Reviewer Guidance (see link below) is the source document reviewers use when confirming code assignments for the purposes of risk adjustment. It contains some helpful guidance:
Problem Lists (within a medical record)
Problem lists are evaluated on a case-by-case basis when the problem list is not clearly dated as part of the face-to-face encounter indicated on the coversheet or there are multiple dates of conditions both before and after the DOS.
Lists of conditions written by the patient are not acceptable.
Lists of code numbers without narratives are not acceptable.
Mention of EMR population of diagnoses in a list will be considered on a case-by-case basis for RADV once all other coding rules and checks for consistency have been applied.
?All of these sources appear to reach the same conclusion: Accurate problem lists can be helpful for getting to accurate diagnosis assignment or as a helpful source of query. But because they’re often inaccurate, outdated, or undated, they should be used with considerable caution.
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Mere lists of diagnoses lack direct clinical support, so they should not be the sole basis of code assignment; they must be confirmed with clinical support in the body of the medical record.
If a diagnosis is on the active problem list, supported in the body of the medical record and meets UHDDS reporting criteria, some organizations permit it to be coded. Others require the diagnosis be carried over/redocumented in the body of the medical record.
This is what I could piece together at least. I welcome other’s opinions on this issue.
Now for some maintenance suggestions.
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Keep it clean
Problem lists require effort to maintain. When acute diagnoses are no longer valid they should come off the active problem list. Chronic conditions should be regularly reviewed.?
Unfortunately this is often not the case. Providers get busy so they become a collection of outdated information, a mix of active and valid diagnoses.
Who is responsible for cleanup?
The obvious answer is the provider. We tell our kids, “You make the mess, you clean it up.” Why not physicians?
The problem is many providers are already overburdened with administrative tasks. Adding problem list cleanup is often a bridge too far.
Fortunately, physicians do not have a mandated responsibility as sole maintainers of the problem list. Others can do so, too.
ACDIS and AHIMA in their most recent query practice brief (Guidelines for Achieving a Compliant Query Practice, 2022 Update) state that organizations should develop a policy for problem list maintenance, but leave the specifics of said policy up to the organizations themselves. From the brief:
That’s why I recommend someone like a CDI specialist claim ownership of the problem list. Not actually removing or adding diagnoses without asking the provider but taking the lead on maintenance. For example, working with the provider to mark conditions as current or active, resolved, historical only, etc., and then adding or removing conditions based on provider input.
It seems I’m an outlier, however. Most organizations don’t seem to trust their CDI professionals with this critical task. In a survey I conducted here on LinkedIn last year, only 8% permit problem list maintenance by CDI professionals; 63% leave it up to the provider . See below. This is borne out in a smaller sample in the ACDIS Q&A article below, where only 1 of 5 respondents permit CDI specialists to update the problem list.
Nevertheless, that’s my recommendation. Some others agree. I’m a fan of this comment on my original LinkedIn post: “Have a policy and process built on compliance and top of license skills that leverage your highly trained and reliable CDI experts. Validate changes with providers - stop expecting them to do all the housekeeping. Imagine having complete and accurate problem lists across the care continuum!”?
In summary, don’t code straight from problem lists. But if you keep them clean they can be a valuable tool in your arsenal.
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References
Emerging Medical Coder | Urgent Care Billing | Risk Adjustment | Multi Specialty ICD-10-CM | CPT | HCPCS | ICD - 10 - PCS | Goal oriented | problem solver | Neurodivergent
6 个月I really enjoyed this reading, and I am team CDI for problem list maintenance. It seems silly to have resources such as CDI in your practice and not leverage the tools available to keep you compliant. I understand that's it's still a newer idea having the problem list accurately maintained ?? Let's be real. The % that leave it up to their providers do not have set expectations that it will be maintained. Living in a ??♀? it is what it is ??♀? environment can get sticky real quickly. In a world where resources and tools are available to do something, take the time to learn how to use them. The time you spend now will prevent a painful waste of time later. Just my 2 cents ?? I'm learning my way into the field of medical coding, and I appreciate learning what tools and resources are available to help me work smarter, not harder ??
Ambulatory Coding and Documentation Specialist at Penn Medicine
6 个月Thank you Brian. You left nothing unsaid. Every T crossed and I dotted. Thank you for organizing this problem list info in a very clear format. Sharing with my team.