Wiki Medical Non Comliance

[coop22]

I am new to coding E/M and was coming across medical non compliance in a HPI. We have very ill patients most of the time and all 4 slots can be taken. Should V15.81 be looked into more often if needed? Any feed back would be appreciated.

 

[Pam Warren]

I typically consider medical non-compliance with regards to risk, same as if there is a condition with an uncertain prognosis. Non compliance can factor into the history with regards to context, but the fact that the patient is not doing what they have been instructed, means that the outcome is questionable. If they're not already at moderate risk, I'd place the non-compliance to help support that level.

 

[coop22]

Thank you for the response. That helps.