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AmandaW

AmandaW

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When auditing E/M, would history of cancer be considered an established problem on the Number of Diagnoses or Treatment Options??

And actually a history of anything if they are still being monitored for it?
 
"History of" indicates an inactive problem for which there is no current treatment ongoing. If they do follow up for surveillance (i.e. CT scans, for example), then you'd consider it an established problem, as long as there was some mention of it in the HPI, system review or exam and that it was addressed in the assessment/plan with attention to any followup or with regards to any current problems. It's hard to support an additional diagnosis from an E&M level perspective, if the only mention of it is in PFSH or in a list of diags in the assessment. In that case I wouldn't count it as an additional diagnosis, because they really have to have addressed it within the body of the note.
 
Thank you Pam! Yes, they definitely address it throughout the note. One of the main reasons for being seen/followed up on therefore I will count it.
 
On the score sheet, under number of diagnoses or treatment options, do the comorbitities/diagnoses in the past history apply? Or can I only use what he adressed in the Assessment/Plan & HPI?
 
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