Wiki E & M Problem Points/Diagnoses

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medicalsec

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My doctors are surgeons and they of course mention previous conditions/often current conditions in the ROS ( Example: History of hypertension/COPD/diabetes. They may also mention them in the HPI, but when they give their final assessment they often only mention the final DX such as Hernia, Cholecystitis, etc. In order to count the problems, do they need to restate them in their final assessment such as controlled-diabetes/hypertension/COPD in order to count then in the diagnoses/management options. I have read information that states that these systemic conditions would have a bearing on the management of a surgical patient and should be included even though they are not actually treating these conditions. I am not sure if they are documenting this information properly to get full credit for these conditions since they are never mentioned in their final assessment.

THANKS,

Dee
 
Not problem points but comorbidities

I would not count these kind of historical chronic conditions ... which the surgeon is NOT treating ... as problem points. BUT when determining the level of risk these co-morbidities might increase the level to HIGH RISK (elective major surgery with identified risk factors).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Thanks for your answer. I was reading some information on the E & M University site, and they had mentioned that they could be used for data points if they had a bearing on the course of the treatment for the patient even though the doctor wasn't treating the underlying conditions. I had never used them before in that manner. I have only used them in reference to the Table of Risk table. It is amazing how many different interpretations that you get on these issues.

Thanks,

Dee
 
cpt for missed appointments

Could someone familiar with billing for missed appointments tell me if there is a CPT code out there that could be used and where this would be located for future reference.


Thank You:
 
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