Wiki A&P Guidance

[imaginethat23]

Our providers see patients in hospital and nursing facility settings and several providers will list every single problem the patient has in their A&P, even if they are not addressing all problems during that day's visit. Just listing the problem in the A&P section wouldn't qualify as counting it in the MDM section, correct? The provider would specifically have to address that issue in order for it to count? I also see notes where they make a change to one of the problems listed in the A&P section but there is no mention of it in the CC or history to explain why.

Thank you in advance. I'm still learning the "gray areas" of E&M and trying to master them has been no easy task.

 

[Chelle-Lynn]

You are correct, to get credit for a condition in the Assessment and Planning, the provider would need to be managing or monitoring the condition listed. Just listing the diagnosis is not enough.

An example of correct documentation would be:

- DM - patient is stable and BS is averaging 120. Continue on meds
- Obesity - patient continues to gain weight, reviewed diet plan and referred to a nutritionist

Just listing the diagnosis as DM or Obesity would not qualify them for "credit" under the E&M criteria. Good catch!