Did it affect the providers medical decision making?
If it did and it is documented, count it.
If it is just getting carried over because it is part of the history and the provider makes no mention of it, don't count it.
You get to count what they are doing so it is not based on the dx code assigned. The patients history of a TIA probably doesn't affect the MDM for a hang nail, but it would for management of HTN.
Hope this helps, I really don't have anything in writing other than the guidelines to direct my opinion of this.
Laura, CPC, CEMC
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