Results 1 to 4 of 4

establish problem worsening

  1. Default establish problem worsening
    Medical Coding Books
    Does the provider have to state that the pts condition has worsened in his chart notes? Alot of the notes that I'm reading say, pt presented with back pain. It is described as aching. The symptom is ongoing, in additon. she presented with pain scale 5/10. Vicodin was prescribed for pain.

    I'm thinking this is an established pt stable.

  2. #2
    So are the meds being prescribed at this present visit? And it sounds to me like this could be a f/u appt to the same issue? Am I correct?

    I'd actually be more comfy seeing the actual note- sanitized of course!
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
    What you've written looks stable to me. In our audits, we explain to providers that the note has to lead us to the fact that its worsening.... if stated previous visit patient was at 2/10 for severity and now 5/10 then it can be construed that its worsening. Its all in the info they provide, unfortunately most providers dont get all of it down in their notes.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  4. Default
    Ok I have the idea now, thanks to both of you.

Similar Threads

  1. New problem or Established problem worsening
    By chriskhans in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 10-02-2015, 12:29 PM
  2. MDM points: established problem, worsening...
    By amexnikki23 in forum E/M
    Replies: 7
    Last Post: 08-25-2015, 02:03 PM
  3. Stable/improving or worsening
    By SUEV in forum E/M
    Replies: 0
    Last Post: 03-19-2012, 12:48 PM
  4. established problem worsening
    By drsunitha in forum E/M
    Replies: 4
    Last Post: 10-10-2011, 06:45 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.