Wiki Is "not been treated in the past" a modifying factor?

[CatchTheWind]

Would you consider "not been treated in the past" a modifying factor? And what about a note stating that a treatment has been used, but not stating what effect it had?

I'm thinking that the justification for counting these as modifying factors is the fact that we asked about modifying factors. Don't we get the credit for asking? (ie: If the note says "patient does not remember when this problem started," wouldn't we get credit for "duration."

 

[Lynda Wetter]

My opinion is no. A moifying factor nneds the out come.

 

[Bjohnse1]

I would say it does no tmaeet the criteria. From my understanding, modifying factors means 'what makes the pain/condition better or worse'. So saying that there is no prior treatment does not answer that question. But that may cover the 'past history' portion of the exam.

 

[okiesawyers]

No, this is not a modifying factor.

To get credit for this there must be documentation of what they've tried to make it better as well as the result.

An example would be: patient has been taking ibuprofen for their headache, no improvement.

 

[jofoley]

I just posted a similar question about using negative responses for HPI element credit - my compliance dept says that it is acceptable to give credit when the physician documents "no modifying factors".

I do not agree.

Does anyone know of any specific documentation in regards to this?

 

[msingh23]

Thanks to all for their contibution I have read all the input and now i am confuse because if the documnetation indicates doing or using something I give credit but reading one of the contributer input the result must also listed outcome, This brings me to if pain is the complainan doc has
"Taking Ultracet for pain but is running out" OR Taking Ultracet OR doing PT
no indiate of outcome does this means no credit for Modifiying Factors

Please advise.

 

[jdibble]

Thanks to all for their contibution I have read all the input and now i am confuse because if the documnetation indicates doing or using something I give credit but reading one of the contributer input the result must also listed outcome, This brings me to if pain is the complainan doc has
"Taking Ultracet for pain but is running out" OR Taking Ultracet OR doing PT
no indiate of outcome does this means no credit for Modifiying Factors

Please advise.

The term is modifying factors - you need to state how something is modifying or affecting the problem.

Unless there is documentation of the outcome of the modifying factor - "taking Ultracet lessens the pain" or "PT has not helped with the patient's pain" it would not be used as a modifying factor. In your examples - "doing PT" or "taking Ultracet for pain but is running out" - this does not show how this has affected the pain, or modified it. This just states that the patient may need a refill.

Hope that this clears up your confusion.

 

[msingh23]

Thanks for your fedback this make so much sense, for when I start coding it was not how I got it but now I am stonger so thank you.