# 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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## Sandy Stevens (Apr 17, 2011)

A diagnosis is "counted" if it was evaluated and managed during the encounter. Documentation guidelines state, "It may be explicitly stated or implied in documented decisions regarding management Plans and/or further evaluation", for instance, ordering a test implies further evaluation. However, documentation should be explicit in describing treatment initiation and changes, referrals, consults “to whom or where the referral or consultation is made or from whom the advice is requested”. 

Nothing beats explicit though, huh? – Medical providers should be strongly encouraged to document in this manner. It doesn’t have to be voluminous, only substance. 

Examples of explicit, but concise Plan documentation might be, “continue current treatment” (treatment must be evident to reviewer); “encouraged compliance”; “continue to monitor”; “pt to keep home log and report (call/or next visit)”; “continue f/u with physician(s) [other medical providers participating in care]”; and similar such recordings. Additionally, a Plan also includes recommended follow-up and/or advice to call if not improving, worsening, report side effects, return prn, keep previously scheduled appointment, etc.  

Unless quoting the guidelines and the examples offered answered your question, it would be helpful to know clinical circumstances, and what exactly is documented in your example, in which there is no noted Plan.


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## btadlock1 (Apr 17, 2011)

*Well said!*



Sandra K Stevens said:


> A diagnosis is "counted" if it was evaluated and managed during the encounter. Documentation guidelines state, "It may be explicitly stated or implied in documented decisions regarding management Plans and/or further evaluation", for instance, ordering a test implies further evaluation. However, documentation should be explicit in describing treatment initiation and changes, referrals, consults “to whom or where the referral or consultation is made or from whom the advice is requested”.
> 
> Nothing beats explicit though, huh? – Medical providers should be strongly encouraged to document in this manner. It doesn't have to be voluminous, only substance.
> 
> ...



Don't forget medication refills, as long as there's a note mentioning the medication and how it's working, like: Pt reports feeling less anxious since starting Lexapro. Quality, not quantity!


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## Sandy Stevens (Apr 19, 2011)

Exactly Brandi.
Hey, one Case-of-the-Day example provided by Dr Peter Jensen, CPC of EM Unversity is titled "29 words". The 29-word note supported 99213, proving it's not the amount of ink or number of pages that supports an E/M service level. I love that resource. 
Y'all have a good.
Sandy


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