Wiki 2 or more stable chronic illnesses under "Number and Complexity of problems addressed"

wynonna

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Hello and looking for assistance with new 2021 guidelines for MDM:

We sometimes discontinue an Rx because the patient's symptoms have resolved. Does this count as 1 stable chronic illness with Rx management?
I've been seeing this one Rx discontinued documented along with another stable chronic problem and I see a level 4.
Is this correctly billed as a level 4 for an established patient?
thank you
 
If there are 2 stable illnesses being treated, and a decision to discontinue a prescription, that is a level 4 (new or established) under 2021 office/outpatient coding. You state "documented along with another stable chronic problem." Just don't forget documenting a problem without treating it does not allow you to count that problem. Only problems treated by that clinician on that encounter are used for leveling.
 
Definition of treatment? Rx management, OTC recommendation, problem contributing to overall treatment plan?
What are some other examples of treating an illness? Does making an evaluation of a dx, or coming up with a new one during gathering history and reporting abnormal findings on an exam count in any way?
How about ordering tests--is this considered a dx under treatment? (I know it counts under data review but how is it counted under "Number and complexity of problems addressed?"
Also, if a diagnosis is in as assessment, but not mentioned in the plan, can we count it?
 
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