Coding the problem list

July 30, 2018 / By Monica Sanchez

The problem list is well known to the medical coding industry since codes based on the problem list are used for research and reimbursement. With the advent of the patient portal, more patients are becoming aware of the problem list too, including how their problems are coded. To better understand the problem list, let’s go back to its origin.  In the 1950s, Dr. Lawrence Weed first developed a system used to organize patient data. He was dissatisfied with the illegible, handwritten notes providers wrote about patients, a practice he considered chaotic. To bring order to the process, Dr. Weed developed the Problem Oriented Medical Record, for which he is revered as an industry pioneer. From this development, the problem list emerged and is now used almost nationwide.

Dr. Lawrence Weed challenged the status quo. He challenged the notion that doctors could rely on memory and personal judgment instead of utilizing tools to adequately keep track of their patient’s problems across specialties. The problem list has evolved to a database of all the patient’s diagnoses and a tool providers use to keep track of and share patient information.

As patients become savvier in using technology, they are more actively involved in reviewing their problem list and identifying errors. Any incorrect code assigned from an improper diagnosis can cross over into the problem list and negatively affect the patient, including possible issues with insurance coverage, effort required to get an incorrect code corrected, and even legal issues—all stressful situations.

The problem list can be documented as Patient Active Problem List, which suggests a list of only those conditions in the patient record that affect the patient’s care. However, the problem list has become a list of every single diagnosis assigned to the patient whether it’s current, chronic, affects the patient’s care or not. As coders, we would not arbitrarily assign codes to these conditions. Clinicians need to manage the list to ensure that it’s complete, current and accurate. Until this happens, coders must continue to review the patient record to ensure diagnoses documented in the problem list meet reporting criteria.

Monica Sanchez is an outpatient coding analyst at 3M Health Information Systems.