The PHYSICIAN must document
I completely agree, colorectal surgeon, that COPD would be a co-morbidity for surgery (as would DM or a host of other chronic or acute conditions). HOWEVER ... this post isn't about assigning risk for surgery. It's about assigning risk for a medical E/M visit.
More importantly ... I am not a physician, and I cannot assume that a patient's condition is worsening or unstable. The physician must document this. Even if doctor states that a patient's POX is 90, I cannot interpret that to mean the patient's COPD is worsening or exacerbated.
This is a chief reason why MDM is so hard to code. Physicians are not always very good at documenting their thought processes. THEY know what the lab numbers mean; other physicians who may read the specialist's note will know what these numbers mean. But the coder can only code what the physician has documented. So, please, physicians - give me details. Give me differential diagnoses. Give your professional medical opinion on the severity of a patient's condition(s). Help me to help you.
F Tessa Bartels, CPC, CEMC