Wiki E/M Questions

[Dug94Jen]

Would someone be able to help me clarify the proper way to use the information that is listed in "Past Medical History"? If an illness is listed under past medical history (e.g. hypertension) are we allowed to use that illness as a "current" diagnosis? Or since it is listed under past medical history are we only able to use it under ROS, when we don't have enough info for ROS?
thank you

 

[deedeefronius]

Past medical history is informational

Unless the patient is presenting with symptoms at the time of service. Past medical history will help you decide what code to you use depending on the length of time, systems reviewed and amount of medical complexity.

Hope this helps answer your question.

 

[blonde01]

Unless the patient is presenting with symptoms at the time of service. Past medical history will help you decide what code to you use depending on the length of time, systems reviewed and amount of medical complexity.

Hope this helps answer your question.

I agree. Also, once a patient is diagnosed with Hypertension, it is likely they still have it but is being treated with medicine.

 

[FTessaBartels]

Past Med Hx NOT diagnosis

I would NOT code something that is mentioned ONLY in the past medical history or ROS section.

If your physician is not treating the patient for this condition it doesn't belong as a diagnosis on your claim.

Hope that helps.

F Tessa Bartels, CPC CEMC