Chronic Disease Documentation and Fees

Sample Note — Single Chronic Disease (Knee Arthritis)

Addressed Thoroughly

Knee arthritis

QOL – Mild pain most times, worse at end of day, 7/10 at worst, better with meds

Functionality – Walks 1 mi many days, drives/shops/chores OK

Med Rec – Takes Naproxen bid most days, Tylenol for breakthrough, no GI issues

PE – bil knees – crepitus, good stability, no effusion

P: RF Naproxen 500 mg bid prn for 1 year

Continue Tylenol prn

BMP now

Sample Note — Single Chronic Disease (Asthma)

Addressed Thoroughly

Quality of Life – Uses rescue inhaler 3-5 times/week, awakened by coughing about 3X/month, no bad attacks

Functionality – Full, almost all days

Medications – Albuterol prn. Pt uses reasonable technique.

Physical Examination — Mostly NAD (means nothing abnormal detected), except for a few mild wheezes

Test Results – None

Assessment/Plan – Mild persistent Asthma — Add inhaled daily steroid

RTC 1 mo

Sample Note — Single Chronic Disease (HTN)*

Addressed Briefly

HTN

Taking meds, no SEs (side effects)

PE: 136/88, NAD

P: RF HCTZ 12.5 mg daily for 1 year.

BMP now

*Hypertension should almost never be billed as a thorough issue addressed, because there are most often no symptoms and little physical exam to perform in most cases. If you spend a lot of time discussing unusual aspects of the care of this chronic disease, bill the appropriate Issue Addressed (IA) code (i.e., moderate or brief) and count the extra time beyond that expected for these codes as an Extra Time code. For example, if you spent 10 minutes just discussing testing and treatment options for a patient with severe disease, bill a moderate level IA code (approx. 4 minutes assumed) and an extra 6 minutes under the ET code for shared decision making.

Sample Multiple Chronic Disease Note

Quality of Life – Breathing is comfortable at rest, gets bad pretty fast. Knee pain 10/10 at worst, better with meds, but often doesn’t take prn Tylenol, mild swelling both knees. Back pain doing well.

Functionality – Can walk about 100 ft. before she has to rest b/c of both SOB and knee pain. Rarely pushes herself for exercise. No recent injury.

Medications (assumes the specifics of doses and timing are on a summary page in another location in the medical record) – Taking albuterol, anticholinergic, and steroid consistently. Taking LABA inconsistently. Ran out of naproxen 1 mo. Rare OTC Tylenol, waits until pain really bad. Taking metformin, ACE, and HCTZ consistently.

Physical Examination – 132/85 93% RA, No acute distress, speaks full sentences, Lungs – distant sounds, scattered mild wheezes. Bil knees – crepitus and mild effusions

Test Results – BMP-nl, A1c 7.8, CBC – nl

Assessment/Plan –

COPD – Take LABA daily, refilled, reviewed acute v. chronic use, increase daily exercise

Knee DJD – Increase prn Tylenol, anticipate pain better.

HTN – good control, RF all meds for 1 year

LBP – good control

DM – reasonable control

RTC 1 mo with PTC BMP