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1995 Guideline E&M Question

  1. #1
    St. Louis, Missouri
    Default 1995 Guideline E&M Question
    Medical Coding Books
    A patient came in to see us for a hernia evaluation but when going over past medical history states that he has hypercholesterolemia-stable. When using the 1995 guidelines under medical decision making, number of diagnosis or treatment options I would count 3 under new problem (to examiner); no additonal workup planned for the hernia. My question is, can I count 1 under self-limited or minor for the hypercholesterolemia-stable condition if this is something we do not see the patient for?

    Melissa Blow, CPC

  2. Default
    You're right to question that. It would not be counted because truly it's not something your provider is treating and isn't a comorbidity of the hernia. It's just past medical history of illnesses and injuries.

    Hope that helps,


  3. #3
    Greeley, Colorado
    Since your doctor is not treating for that condition, no it should not be counted in your MDM. It is part of the patient medical history.

  4. #4
    St. Louis, Missouri
    I did not think that I could but I just wanted to check some other opinions- Thanks!

    Melissa Blow, CPC

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