For the 3 C's you actually have to list each and give sort of a status update in the patients own words.
Example: HTN- states home pressures are running a little high, continues to take meds but has not changed diet
COPD-complains of increased shortness of breath when walking
DM-per home log sugars are running high, but patient is still not compliant with diet modifications.
On the Rx management, a list of current meds is just past history, the provider actually has to be dealing with the drugs they are on to get credit. They don't have to change anything, but they need to indicate it was part of their MDM.
Example: HTN-stable, continue current meds
On the table of risk, it is the highest you get in any of the 3 categories. So even if your presenting problem falls under low (acute uncomplicated illness or injury) if your management option selected is Rx management, your risk is actually moderate.
Hope this helps,
Laura, CPC, CEMC
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