Focus on Date for Problems Addressed, Unaddressed
Question: When I’m looking at a patient’s medical record, how do I know whether the provider has addressed a problem or left it unaddressed? South Dakota Subscriber Answer: When trying to determine the level of medical decision making (MDM) for evaluation and management (E/M) services, coders may be confused about “problems addressed” and “problems unaddressed.” The AMA, in its 2023 E/M guidelines document, defines a problem as “a disease, condition, illness, injury, symptom, sign, finding, complaint or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.” According to AMA guidance, a problem is addressed “when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.” This may include consideration further testing or treatment. If the medical record shows via a notation that another provider is managing the problem, or there’s a referral without evaluation or consideration of treatment, then the AMA would consider such problems unaddressed, per MDM. Important: For inpatient or observation care, a problem addressed is on the date of the encounter and may differ significantly from any problems present at admission. Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
