Wiki Counting Managed Conditions

[mlandrus]

Hello,

I am wondering if I could get some opinions on what you would count as a "managed" condition.

For example, if a provider documents a condition in the HPI and then lists it in the Assessment, but there is no mention in the Plan or Discussion/Summary, is that enough to count towards the MDM?

Or vice versa, there is no mention of the condition in the HPI, but it is listed in the Assessment and in the Plan and Discussion/Summary. Should this count towards the MDM?

Or if the provider renewed meds or ordered labs without mentioning the condition elsewhere in the note, should this condition be counted as well?

We are looking for some guidance so that we can create our own internal policy regarding this issue.

Thank you in advance!

Martha

 

[Kris Cummings]

I think you'll find what you're looking for in this link: http://www.hcpro.com/content.cfm?content_id=302031, that discusses M.E.A.T. in documentation.

The acronym stands for:

• Monitor—signs, symptoms, disease progression, disease regression
• Evaluate—test results, medication effectiveness, response to treatment
• Assess/Address—ordering tests, discussion, review records, counseling
• Treat—medications, therapies, other modalities

​
The essence of this describes if any of these are done, then it's a problem/condition that bears reporting.

Personally, when I see orders for diagnostic studies, or medications renewed, without further elaboration in the note, I use that as an educational tool and moment for the provider. IMHO, I educate that if you're discussing it, examining it, and/or assessing it, document what you've done.

I hope that helps.