# MDM Question



## daniel (Nov 19, 2009)

I'm saying yes, but going of this.  


Is this a HIGH MDM.


I already pushed this through and upcoded it to a 99233.

I'm just trying to get a feel for interpreting this, I came from a Family Practice setting doing E/M, and thats a different mind frame from interpreting Family Practice MDM vs Intensivist MDM. 



Impressions/plan:
# Altered Mental Status: likely related to meds.  Now awake and responsive

# Pulmonary
1. acute resp failure s/p ETT 11/3-11/10
2. bilateral aspiration pneumonia
3. COPD
4. hypoxemia: combination of pneumonia, V/Q mismatch, atelectasis
5. OSA
	-keep euvolemic
	-cont oxygen support, wean as tolerate
	-cont abx for tx of pneumonia: zosyn per Dr Ho for 4 more days
	-pulm toilet, bronchodilators, IS, mobilization
	-encourage CPAP with sleep for OSA
	-wean steroid off 11/14


# Cardiac
1. Moderate AS
2. HTN
-keep euvolemic
-cont coreg, diovan and calcium channel blocker for BP control

# Endocrine
1. DM II: hyperglycemia exacerbate by steroid now off. Pt has hypoglycemia
2. Hypothyroidism
3. Hyperlipidemia
-followed by endocrine and stable on meds

# PICC line associated DVT
-coumadin x 3 months
# Leukocytosis, source not clear, r/o C diff colitis vs line sepsis
 picc line DC 11/16, check tip culture
check C Diff, agree with oral vanco
#PPX-> scd and acid lowering,


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## daniel (Nov 20, 2009)

Any takers


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## FTessaBartels (Nov 20, 2009)

*Mdm*

Daniel,
MDM is determined the same way regardless of the specialty, place of service or type of service.

To get a high level MDM you need TWO of three
Problem points - at least 4
Data points - at least 4
Risk - High complexity

You easily have 4+ problem points - mostly because you have so many problems. This is a subsequent hospital visit, so these are all established problems (unless any one of them was a new development since yesterday, but the doctor would have to say so).

From the A/P you post I have no idea if you have any data points.

So it comes down to whether or not you have high complexity risk.
If you meet *ANY one *of the following you have it:
* One or more chronic illnesses with *severe exacerbation*, pregression or side effects of treatment
*  Acute or chornic illnesses or injuries that may pose a threat to life or bodily function (e.g. multiple trama, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure)
*  An abrupt change in neurologic status (e.g. seizure, TIA, weakness, or sensory loss)
* Cardiovascular imaging studies w/ contrast *with identified risk factors*
* Cardiac eletrophysiological tests
* Diagnostic endoscopies *with identified risk factors*
*  Discography
* Elective major surgery *with identified risk factors*
* Emergency major surgery
* Parenteral controlled substances
* Drug therapy requiring intensive monitoring for toxicity
* Decision not to resuscitate or to de-escalate care because of poor prognosis.H

Hope that helps,

F Tessa Bartels, CPC, CEMC


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## daniel (Nov 23, 2009)

Thank you for the response.


I guess my confussion is, when the patient is established in the hospital setting (ICU).

And the patient has one of the following diagnosis, 

but the physician indicateds the patient is stable on current treatment.

Or documents continue with supportive care

Or   contiue with aggressive pulmonary toilet, oxygen, nebulizer therapy, chest physiotherapy, low threshold to perform endotracheal intubation should the patient's respiratory condition worsen further.



Acute MI

Severe respiratory distress

Acute renal failure

Altered mental status do to medication


Do these scenarios still fall under High Risk for the MDM, or does it fall to a Moderate MDM because nothing has changed in the treatment or digagnosis.


Daniel


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## Bernadette10 (Feb 5, 2019)

*High MDM*

My understanding of this is that if it's the first time the provider is seeing the patient for the severe exacerbation, progression or high risk problems for that admission, then it's high MDM. But if it's a subsequent visit for the same problems and the patient has been stabilized, then it's moderate MDM.


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