1995 Guideline E&M Question

[mmelcam]

A patient came in to see us for a hernia evaluation but when going over past medical history states that he has hypercholesterolemia-stable. When using the 1995 guidelines under medical decision making, number of diagnosis or treatment options I would count 3 under new problem (to examiner); no additonal workup planned for the hernia. My question is, can I count 1 under self-limited or minor for the hypercholesterolemia-stable condition if this is something we do not see the patient for?

[Kris Cuddy]

You're right to question that. It would not be counted because truly it's not something your provider is treating and isn't a comorbidity of the hernia. It's just past medical history of illnesses and injuries.

Hope that helps,

Kris

[Lisa Bledsoe]

Since your doctor is not treating for that condition, no it should not be counted in your MDM. It is part of the patient medical history.
Lisa

[mmelcam]

I did not think that I could but I just wanted to check some other opinions- Thanks!