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Age of labs/scans in diagnosis documentation

K

kblaska

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Waterloo, WI
If a provider documents the following on a 2023 dated visit: Left renal artery aneurysm monitored with CT last on 12/25/2021. Continued surveillance. under the HPI section. Would you still code this as a chronic condition? I haven't found any guidelines where the age of a lab/scan should be taken into consideration when assigning a diagnosis if the provider is including other components of MEAT or TAMPER.
 
borderline- if you are able to review the documentation in real time, and can ensure that the provider has not copied and pasted this statement from 2021, 2022, and now 2023, then possibly. I would consider this bare bones acceptance of an HCC. I would also be hesitant to capture this if this statement is only applied to a single encounter in 2023.
 
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