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nikkimalahan

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When doing E/m for behavioral health, if the chronic conditions are not listed or mentioned in the body of the note, can i use them for MDM? Our templates have a DX section at end where they are listed and a status indicator, is that good enough for MDM? For example If the pt has ADHD which is talked about in the HPI, then listed in the DX table at the end of the note is MDD and Anxiety. Can I count those towards MDM even though they are not addressed or mentioned in the body of the note?
 
If the diagnoses are assessed with a comment/plan of care then, yes, you should count them for medical decision making e.g. two stable chronic conditions. As of October 2014 i think, you can you follow up of 2 conditions for the history but the notes must state, patient presents for follow for MDD and ADHD.
 
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