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Need Help Counting MDM Points!!

anne32

Networker
Messages
88
Best answers
0
I have a chart where the patient came in to get refills on all her medications but the HPI only lists the status of one chronic condition. In the Assesment section, the note talks about other chronic conditions- Epilepsy, Depression, OA, and Asthma and that the provider is refilling meds for all those. My question is do I count all those in the MDM-A section or do I only count the one chronic condition that the status was mentioned in the HPI?
 

Kris Cuddy

Guru
Messages
204
Best answers
0
The HPI for "status" of three or more chronic conditions is not about the provider's assessment of those conditions. It's about the patient's statements of the conditions. It's the subjective status of the conditions. If the provider documented HPI in the "assessment" area of the chart note, then I'd count it. If the provider is documenting his or her assessment, then I would not count it.
 
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