Mdm

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If in an encounter, the doctor documents 3 diagnoses in the Chief Complaint and the Assessment & Plan, but in the chart note only one of the 3 is addressed, should all 3 diagnoses be considered in MDM?

Please advise. Thanks.
 

jonique.dietzen

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Question, isn't the assessment and plan a part of the chart notes?

There doesn't necessarily need to be an exam for each diagnosis, but there should be a documented (in the notes) assessment and plan for each diagnosis addressed. Example, there won't necessarily be an exam for diabetes, but the A&P may state "DM 2 well managed with current medications, new rx given for metformin and test strips". In this case diabetes would count toward the MDM for the visit.

But, if the A&P just states "E11.9 - Type 2 diabetes mellitus without complication", this would not count toward the MDM because there is no actual assessment or plan, just a statement that the patient has the condition.

Jonique Dietzen, CPC
 
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