panoramic shot of doctors holding papers in clinic

Unfortunately, the problem list is organized the way it is.

The problem list is a problem. We talk about this, but I think we don’t explore why it is such a mess.

I spent ten minutes with my primary care physician cleaning up my problem list last month. I no longer have a mass on my left foot, although I did have a digital mucous cyst which was excised in September. Even that specific diagnosis should no longer be on my problem list because it is gone now. I should be just left with Z98.890, Other specified postprocedural states, to reflect my foot surgery, but is that a useful piece of information?

When we were on paper, the front page of the clinic patient’s chart had a running list of problems that the primary care provider had addressed over the years. It was messy with entries crossed out and scribbles in the margins to try to avoid having to go onto another sheet. Its purpose was to remind the provider of conditions that the patient currently or historically had. This is also known as a summary list, mandated by the Joint Commission for patients who receive continuing ambulatory care services.

In the electronic world, the problem list is intended to be the source of truth for the longitudinal care of the patient, and it encompasses both ambulatory care and inpatient services. It is accompanied by ICD-10-CM codes which may not be correct or optimal. If a condition is imported into the current encounter from the problem list but the problem list is not accurate, the details of the visit could be corrupted. Without ongoing curating, the problem list cannot serve as the source of truth.

Providers use a problem list to remind themselves what the patient has (e.g., their acute and chronic active conditions) and what they had (e.g., historical problems which may be important to recall in the context of the current situation). Providers don’t understand or care about the “history of” coding designation. Converting a precise, specific condition to a nebulous “history of” status code in a list where you are trying to keep track of a patient’s medical conditions might be counterproductive.

If a patient has Z86.79, Personal history of other diseases of the circulatory system, did they have endocarditis or ventricular tachycardia, or an occlusion of a central retinal artery? If they have a personal history of other infectious and parasitic diseases, did they have chickenpox or hepatitis, or Ebola? It could make a big difference!

It might make sense to a provider to leave a code in place if they feel it will give them information. Paroxysmal atrial fibrillation means an irregular heartbeat that comes and goes. It might make sense to them to leave it on the active problem list, even if the patient is currently in sinus rhythm. When a patient follows up for an acute illness and it has resolved, is that the visit when the conversion should take place? Does Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, communicate, or is it just intended for billing purposes?

Coders are permitted to update problem lists but not on their initiative, and the documentation must support the revision. If the patient comes in three weeks after admission for aspiration pneumonia and the provider documents that they are all better, but then erroneously records, “pneumonia” as the impression, can the coder translate that into Z09 plus Z87.01, Personal history of pneumonia (recurrent) for the visit and update the problem list by removing J69.0?

Unfortunately, the problem list is organized the way it is. It would be more useful clinically if you could maintain a list of previous issues to tickle your memory. Some organizations have the EHR functionality to archive or resolve a problem without it completely dropping off the list as if it never existed. Having previous aspiration pneumonia may indicate a tendency towards aspiration. That might inform future medical care.

Providers do not like revising, updating, or removing conditions that were placed on the problem list by a different provider. What if the patient never sees that specialist again? What if a provider retires or dies? Whose responsibility is it to keep the problem list accurate? My PCP didn’t know anything about digital mucous cysts; she trusted that I did because I am a physician and an educated patient. I’m not sure she would have felt comfortable removing the diagnosis if it weren’t I who was instructing her to do so. I’ve taught her a lot about documentation and coding over the years, and I do relish a tidy problem list.

Providers are being asked to do more with fewer resources. If they don’t feel the problem list is a value-added to their practice or patients, they will not be inclined to invest the considerable time it takes to maintain the problem list. Where does the buck stop?

I don’t have the answers about how to resolve the issues around a problem list, but AHIMA has some suggestions. Organizations must establish policies and procedures to ensure that the problem list is kept up-to-date and accurate. HIM and CDI personnel can be built into that system to try to make the problem list less problematic.

Programming Note: Listen to Dr. Erica Remer on Talk Ten Tuesdays, where she co-hosts with Chuck Buck.

Resources:

AHIMA. “Definition, History, and Use of the Problem List.” Journal of AHIMA 90, no. 7 (Jul-Aug 2019): 44-49.

AHIMA Work Group. “Problem List Guidance in the EHR” Journal of AHIMA 82, no.9 (September 2011): 52-58.

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