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Wiki Help Please! history codes

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strawn123

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I have a question about v12.54 and other history of codes and the 95 guidelines. I know the code is reportable, but what about counting it in MDM? Do you give credit at all? If so just give credit for an est. problem stable imporoved?? The office is divided on the issue so I am asking for outside help and if there is any links to documentation that would be ever so helpful as well.
 
Did it affect the providers medical decision making?

If it did and it is documented, count it.

If it is just getting carried over because it is part of the history and the provider makes no mention of it, don't count it.

You get to count what they are doing so it is not based on the dx code assigned. The patients history of a TIA probably doesn't affect the MDM for a hang nail, but it would for management of HTN.

Hope this helps, I really don't have anything in writing other than the guidelines to direct my opinion of this.

Laura, CPC, CEMC
 
Thanks,

On this particular one they were just doing routine followup for Hypertension. That was the problem because I knew HTN was a problem associated with the TIA. With this particular provider MDM is the tiebreaker on our code level everytime. HTN is stable and those are the only 2 diagnosis that are given so if we do not cout it it is a 3 but if we do count it it is a 4.
 
I'm not really sure I understand how this could make a difference between low or moderate MDM.

If you have stable HTN, that is only 1 point. That would actually stick you at a 99212, unless you have data points in which case the dx points wouldn't be in question to start with.

Laura, CPC, CEMC
 
Ooops that is my fault it was not stable it was slightly elevated so we had it at a 2. No testing was done so we have it at 2,0, and moderate for mild exacerbation. You add the history of TIA and it kicks your code up because it then goes to 3,0,moderate.
 
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