Wiki Mdm?

[tcoder5]

Physician documented in history that pt has leg cramps at night. He did not document anything for the leg cramps in the assessment/plan. Does this mean he cannot get a credit for the leg cramps in the dx section of MDM? I am thinking he either forgot to document the leg cramps or he did not address it.

 

[sdunn]

Addressing Leg Cramps

Hi Poster,

I would look in the PE (Physical Exam) to see if the physician addressed the leg cramps, if so then yes you can pick it up, but I would also have the provider ammend the record and add the Leg Cramp in the assesment. Any time a condiction is EVALUATED, ADDRESSED OR ASSESSED it is codeable.

 

[tcoder5]

Thanks so much!