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Wiki Evaluation and Management/Medical Decision Making
- Thread starter gwen2475
- Start date
btadlock1
Guest
No - the doctor didn't make a medical decision about it. If he refilled a prescription for it, and there's a status in the HPI stating how the treatment plan is working, then you have enough to count it. Otherwise, it's just FYI, and doesn't really affect the E/M level. Hope that helps!~
FTessaBartels
Guest
Problem points or Risk?
Are you asking how to determine the problem points or the risk factors?
-OR-
Is this a "diagnosis" that is just part of a laundry list of conditions the patient has, but isn't being addressed at all in this encounter. (e.g. patient comes to you for simple laceration on forearm, simple repair with DermaBond; list of conditions includes HTN, and Hyperlypidemia)
Please clarify your question and then we can help you.
F Tessa Bartels, CPC, CEMC
Are you asking how to determine the problem points or the risk factors?
-OR-
Is this a "diagnosis" that is just part of a laundry list of conditions the patient has, but isn't being addressed at all in this encounter. (e.g. patient comes to you for simple laceration on forearm, simple repair with DermaBond; list of conditions includes HTN, and Hyperlypidemia)
Please clarify your question and then we can help you.
F Tessa Bartels, CPC, CEMC