Resolved Diagnoses

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Do you count resolved diagnoses in Number of Diagnoses? The patient is being seen for a yearly recheck and the issue is now resolved.

ASSESSMENT:

1. Dysfunctional elimination syndrome, constipation, resolved on MiraLax.

2. Urinary retention, mild, improving with voiding habits and MiraLax.

3. Incontinence, resolved, felt to be overflow with treatment of constipation and good voiding patterns.
 

Pathos

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Hello Kayla,

Whenever I have a gray area in the E/M realm, I usually check the CMS E/M guidelines to see if there is some help to glean from. On page 15 of said guidelines we read:

"Here are some important points to keep in mind when documenting the number of diagnoses or management options.

You should document:
An assessment, clinical impression, or diagnosis for each encounter, which may be explicitly stated or implied in documented decisions for management plans and/or further evaluation:

  1. For a presenting problem with an established diagnosis, the record should reflect whether the problem is:
    1. Improved, well controlled, resolving, or resolved
    2. Inadequately controlled, worsening, or failing to change as expected
  2. For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a "possible," "probable," or "rule out" diagnosis"

If the patient is still having the condition, but the symptoms are controlled by treatment and are being actively managed by the provider; then you can definitely include them in your MDM.

Hope that answers your question!
 
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