The problems count as new under medical decision making. He should comment that they are new problems to the provider (not the patient) as well as give status of the conditions (improving, worse, side effects) and document if he is doing any additional workup on any specific conditon (difference between 3 and 4 points on # of diagnosis).
You are also correct that it would fall under the moderate category for table of risk taking into consideration prescription medication. He is now managing these meds and falls under his liability.
Christie Musser, CPC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join