Problems Addressed
If you are familiar with prior rules, the changes to problems that were managed are the biggest adjustment. The rules now break down problems easily to chronic, acute, simple/self limited, life/bodily function-threatening, and undiagnosed. You can get appropriate categorization of the problems you are managing by adopting simple habits of using important keywords. Check out the brief slide deck on problems, listen to ur brief problems podcast, or print out the one-page handout on the keywords to remember.
Problem Keywords:
- Status of condition: Exacerbated or progressed
- Status of condition: Acute or chronic (previously new or established)
- Multiple treatment options
- Requires additional evaluation
- Side effects from treatment
- Risk or morbidity without treatment or from treatment itself
- Severe exacerbation
- Threat to life or bodily function
Many simple reference handouts have been created trying to get you the information you need at your fingertips when you need to reference it in your busy day. The MASTER Handout is E&M Documentation Guidelines and Definitions for 99202-99215. Keep this one handy and check out the additional one-page items for helpful information.