Wiki Table of Risk/level 5

[medicalsec]

I work for a surgeon who always quotes the comorbidities in the past history, (diabetes, congestive heart failure, etc. When stating the risk factor to the patient, he always quotes bleeding, possible cardiac issues, etc., but he does not refer to these issues as being in the present in the HPI or the assessment. Can I use these as present risk factors for the surgery to bring it to a level 5, or does he need to restate these as being in the present, and should I code systemic issues even though he is not treating the issues to show the risk involved.


Thanks,

Dee

 

[dadhich.girish]

I believe we can only take current issues for leveling, which are discussed by the provider in present encounter.