Wiki Medical Decision Making

[swoollard]

When choosing the number/complexity of problems addressed, moderate shows as 1 or more chronic illness with exacerbation....To determine problem can fall into this complexity does the provider need to actually state that the problem is chronic or can the coder go by in the HPI area where they state problem has been present for 1 yr or 2 yrs? I have tried to place a picture here regarding this but it wont post so I have attached it for you to open to see what I am questioning. Thank you

 

[marandee]

Aren't diagnoses not stated as chronic, coded as acute? Only the clinician should state if chronic (documentation will then reveal if treating exacerbation). The A/P portion of provider's note should specify condition as assessed (all).

 

[swoollard]

Aren't diagnoses not stated as chronic, coded as acute? Only the clinician should state if chronic (documentation will then reveal if treating exacerbation). The A/P portion of provider's note should specify condition as assessed (all).

Thats where I am confused. Lets say the provider states "She states that the symptoms have been present for approximately 2 years and have progressed" but doesn't come out and actually say chronic. Would this be considered chronic if stated like that? I was always told a year or longer would be considered chronic so I am unsure what to do.