# Number of Diagnoses or Treatment Options-In order to get



## CC5657 (Mar 8, 2011)

In order to get credit under "# of diagnoses or Treatment Options", does the physician need to address these diagnoses (stable, uncontrolled, etc) in his plan. Or can they just list the diagnoses (hyperension, type 2 diabetes, etc) in a problem list & get credit for # of diagnoses??


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## btadlock1 (Mar 8, 2011)

KAM5657 said:


> In order to get credit under "# of diagnoses or Treatment Options", does the physician need to address these diagnoses (stable, uncontrolled, etc) in his plan. Or can they just list the diagnoses (hyperension, type 2 diabetes, etc) in a problem list & get credit for # of diagnoses??



Here's the way that I understand it (I feel certain that someone will correct me if I'm wrong)...

To get credit for a Dx/Tx in the MDM, it actually has to have some kind of bearing on the decision itself; so if it's something that might further complicate the problem that the doctor is treating (at that moment), or if it would complicate the treatment of that problem, then it's taken into consideration for the 'risk' portion of the MDM, but it's not counted toward the #Dx/Tx options part of the MDM. (Diabetes complicating wound-healing, is usually a good example)

The question you're trying to answer when picking the MDM is: How severe is this patient's current condition, and what is the doctor doing about it (taking into account the risks involved)? If the patient has HTN, and the physician only mentioned it briefly, the doctor didn't really have to make a 'medical decision' about it; if he managed a prescription (like writing a refill) for it, then he really probably should have documented the status in order to receive credit for evaluating and/or managing it. I hope that wasn't confusing...


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## CC5657 (Mar 9, 2011)

Thank you Brandi. It makes perfect sense!!


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