Wiki How to best determine if a dx is under treatment?

[wynonna]

Definition of treatment? Rx management, OTC recommendation, problem contributing to overall treatment plan?
What are some other examples of treating an illness? Does making an evaluation of a dx, or coming up with a new one during gathering history and reporting abnormal findings on an exam count in any way?
How about ordering tests--is this considered a dx under treatment? (I know it counts under data review but how is it counted under "Number and complexity of problems addressed?"
Also, if a diagnosis is in as assessment, but not mentioned in the plan, can we count it? (as 1 stable chronic illness)

 

[carlystur]

Please, only post your question in one forum. You're more likely to get a response to it if you either edit your original to include as much information about your issue as possible or to reply your self so it'll go back to the top of the page if it's been a while.

 

[wynonna]

I found something helpful:
"A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.
This includes the consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice."
and "Referral without evaluation (by history, exam, or diagnostic study or consideration of treatment) does NOT qualify as being addressed or managed by the MD or other qualified health professional.