Wiki MDM - Chronic Conditions & Risk


Chicago, IL
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Would someone please be able to set me straight on this point?

In determining MDM Risk, do the patient's chronic conditions count, even if they are NOT specifically addressed in the notes, but just merely listed in the patient's "PFSH/Past Medical Hx" inventory?

For example: Est. patient seen for a fol-up for Hepatitis, stable. The PMH lists chronic conditions: DM, HTN, & Obesity. There is no documentation of the 3 other conditions being addressed anywhere else in the note.

My choices on the Table of Risk are then either Low (1 stable chronic illness), or Moderate (2> stable chronic illnesses) If I do count these other issues, then aren't I assuming they affect the pt's presenting problem?

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I would not give credit for the other conditions unless it is documented that those conditions were managed at that visit and are included in the physician's assessment.