Wiki Past Medical History

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catcate

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Does the Past Medical History need to be in the note the day they are seeing the patient? It would be in another section of the chart, but do we need this to be in the note at each visit for MDM?
 
Your history and exam you do have no bearing in the exam coding any more. However, IMHO, if you have the past medical history and it notes diabetes or hypertension and medications or other treatment for those condition, it does justify the medical necessity for the visit, plus it also records the presence of chronic conditions. However, in order to be counted for the MDM code selection, those two chronic conditions would have to be "addressed" during the visit as shown in the exam notes and A/P part of the record.

Tom Cheezum, OD, CPC, COPC
 
Thank you Tom Cheezum! So if I understand you correctly, the provider will have to address these issues and put "reviewed" in the chart at each visit that they address them. Now with that being said does the past medical history have to be entered on the same day the patient is seen? If they addressed it and they the staff doesn't get the past medical history entered until the following day is that okay?
 
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