Problem Lists: Challenges and Opportunities

By Rose T. Dunn, MBA, RHIA, CPA, FACHE

Are your problem lists a problem? Providers have enough documentation burdens already. For providers, maintaining problem lists takes a backseat to patient care…as it should. However, an accurate and complete problem list can facilitate patient safety and care. Coders and documentation specialists have a critical role to play in support of this powerful tool used to tell a patient’s medical story.

You can think of the problem list as a Table of Contents highlighting the major chapters in a patient’s medical history:

  • A compilation of their problems and conditions
    • Active current conditions
    • Chronic conditions
    • Past or “personal history of” conditions that bear on current treatment
    • Significant past or resolved conditions that are no longer actively being treated
  • A resource for clinical decision support tools to prevent medical error and improve patient care

Let me emphasize “significant” when deciding whether past or resolved conditions should be included on the problem lists. The criteria would be to include past or resolved conditions that may help a provider to understand and treat the patient in the present. There is a difference between a long-ago cut on your finger requiring two stitches and a history of cancer.

Problem lists offer benefits beyond the immediate patient-provider relationship. If kept current, problem lists can serve as a source of comparative data for research, drivers for quality measures, and support for secondary data reporting, such as registries.

While we may all agree on the concept of problem lists as beneficial, in practice, problem lists are beset by inconsistency and a lack of standards. The most important risk is that posed to patient care. Maintaining a problem list for a patient that is both accurate and succinct will help practitioners know what is important about the patient at the time the patient is being treated.

Appreciating the value of the problem list to ensure quality patient care and addressing the inconsistency and lack of standards affecting the usefulness of problem lists is both a challenge and an opportunity for HIM professionals.


HCC Problem Lists: Challenges and Opportunities
Are your problem lists a problem? An up-to-date and accurate problem list can facilitate patient safety and care as well as being a key aspect of some risk adjustment contracts. HIM and CDI specialists have a role to play.  Learn more here.

About the Author

Rose Dunn
Rose Dunn is the Chief Operating Officer at First Class Solutions, Inc., a healthcare information management leader since 1988. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She engaged herself in ICD-10 more than 10 years before it was implemented. She is assisting Libman Education in the development of an HCC educational program. Rose holds a BS and MBA from Saint Louis University.

3 thoughts on “Problem Lists: Challenges and Opportunities

  1. Gladys T. - February 12, 2021 at 8:44 pm

    Rose, thank you so much. I love reading your articles. I have a question for you concerning HCC Problem List. Can we add a new HCC “Suspected Condition” to the Problem List? Even thought is not been billed and the provider did not state the diagnoses in the chart?

    And does the Suspected means not documented or billed before but “New”? I am needing some clarification on this Problem List.

    • Rose T. Dunn - February 13, 2021 at 4:26 am

      Hi Gladys,
      Thanks for your kind words. Also, that’s for the question. If the physician doesn’t document it, the suspected diagnosis is not supported. Additionally, in the outpatient environment, suspected cannot be coded, which, I’m sure you know.

      If you think there is a diagnosis that has not been documented, perhaps based on meds or test results, the best approach, in my opinion, would be to query the provider and suggest s/he add an addendum to the record and add it to the problem list. If you work in the practice with the physician, a personal conversation with the physician is much more effective and gives you the opportunity to explain the benefit to him/her.

      Your other question, I think is how to show the diagnosis as “new.” Some EHRs have the ability to display the date the problem was added to the list. Unfortunately, not all. So, adding to the list may require some sequencing, which also may not be supported by the EHR. The whole problem list situation is truly a “problem.” Getting the EHR vendors to listen to us, is more of a challenge. ☹

      Thanks again,

  2. Gladys T - February 15, 2021 at 2:34 pm


    Thank you so much for answering my question and giving me some clarification.