Wiki E and M History

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BarbSlattery

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Can someone let me know how to determine a Past Medial History as part of E &M coding with a chronic condition if the medication list is updated on visit,even though the history has not been reviewed and updated within a year? does this warrant the chronic condition for coding purposes?
 
The medication itself becomes the past history, but for good recordkeeping purposes, it's recommended to have patients update their history/problem list annually.
 
Chronic condition?

Your question is a bit of a jumble ... Brandi answered re past medical history, but you also mention something about a chronic condition.

I think you are asking if listing the medications qualifies as "status of three chronic conditions" (substitute for 4 HPI elements in 1997 guidelines). NO it does not. The important word is "status." They physician must document whether the chronic condition is stable, improved, worsening, uncontrolled, etc.

And, no, adding the lab values doesn't qualify either. The coder is not a diagnostician. The provider MUST specify the status of chronic conditions (3 or more) to meet the requirements for HPI.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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