# Evaluation and Management/Medical Decision Making



## gwen2475 (Apr 15, 2011)

Do you count a diagnosis in MEDICAL DECISION MAKING, if it has no plan??


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## btadlock1 (Apr 15, 2011)

gwen2475 said:


> 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!~


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## FTessaBartels (Apr 15, 2011)

*Problem points or Risk?*

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

*-OR- *

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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