I am studying for CEMC exam (E/M) via Study Guide. In some rationals, they consider illnesses as chronic without documented chronic. I wonder if its correct in a coding world to assume they are chronic? Below I type some examples and thank you for your help in advance.
Case 5:
Atrial Fibrillation: the pt is with history of chronic AF who is
Obesity: Pt is working on this but has continued to have problems.
Hypertension: Blood pressure today was.. She will be followed conservatively.
[I]Rational:[/I] Medical decision making level is :Moderate ( pt has multiple chronic illnesses that the cardiologist is following during the hospital stay)
Case 6:
Atrial fibrillation: Pt with a history of AB .
Mild cardiomyopathy: Pt has mild.. clinically stable.
Hyperlipidemia: This will be followed by Dr.X.
Rational: MDM is Moderate ( due to the number of chronic illnesses treated)
Case 5:
Atrial Fibrillation: the pt is with history of chronic AF who is
Obesity: Pt is working on this but has continued to have problems.
Hypertension: Blood pressure today was.. She will be followed conservatively.
[I]Rational:[/I] Medical decision making level is :Moderate ( pt has multiple chronic illnesses that the cardiologist is following during the hospital stay)
Case 6:
Atrial fibrillation: Pt with a history of AB .
Mild cardiomyopathy: Pt has mild.. clinically stable.
Hyperlipidemia: This will be followed by Dr.X.
Rational: MDM is Moderate ( due to the number of chronic illnesses treated)