Lisa Posted Tue 11th of March, 2014 09:37:09 AM
If a patient comes in for a follow-up of an existing condition like glaucoma and the HPI only lists a brief history, but then assesess other problems like senile cataract and dermatochalasis, when selecting the level of risk of presenting problems, are we to only look at the reason for the visit, why they made an appt or do we consider all the diagnosis assessed?
SuperCoder Answered Wed 12th of March, 2014 22:14:19 PM
If " senile cataract and dermatochalasis " are new conditions found in this F/U visit, all 3 conditions (including existing glaucoma) are to be counted while counting Risk under MDM. Based on this limited info, we would go with "low" level of risk from "presenting problem" section.
One stable chronic illness - glaucoma
acute uncomp. illness - senile cataract and dermatochalasis
Risk calculation does not depend on reason for visit only, it also depends on nature of diagnostic conditions and treatment options.