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Thread: Evaluation and Management/Medical Decision Making

  1. #1

    Default Evaluation and Management/Medical Decision Making

    AAPC: Back to School
    Do you count a diagnosis in MEDICAL DECISION MAKING, if it has no plan??

  2. #2
    Join Date
    Apr 2007
    Lubbock, TX


    Quote Originally Posted by gwen2475 View Post
    Do you count a diagnosis in MEDICAL DECISION MAKING, if it has no plan??
    No - the doctor didn't make a medical decision about it. If he refilled a prescription for it, and there's a status in the HPI stating how the treatment plan is working, then you have enough to count it. Otherwise, it's just FYI, and doesn't really affect the E/M level. Hope that helps!~

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default Problem points or Risk?

    Are you asking how to determine the problem points or the risk factors?


    Is this a "diagnosis" that is just part of a laundry list of conditions the patient has, but isn't being addressed at all in this encounter. (e.g. patient comes to you for simple laceration on forearm, simple repair with DermaBond; list of conditions includes HTN, and Hyperlypidemia)

    Please clarify your question and then we can help you.

    F Tessa Bartels, CPC, CEMC

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