# How would you code this record..



## Ivonne C. (Aug 11, 2010)

Im doing an audit for a physician and I am having a hard time with the MDM.

CC: Pregnancy Verification; LMP 9/15/09 irr. cycles. Bled X 1-2 days in october with cramps.

ROS: 13 systems reviewed

EXAM: wt: 314ib. Ht:64.5in. BMI:53.1. Obese A/A female in no acute distress. Affect is normal and appropriate. Mucosa pink and moist. Chest is CTA. Heart RRR without murmers. Gait is WNL. Abd: Obese. soft. nontender. FH@153BPM. fundus-16w.

Ordered: an OB ultrasound.

my question is since the pt is obese and puts her at a higher risk does that make the visit a moderate risk level or since there isnt any complications noted is it a lower level MDM. another question i am having is pregnancy as a chief complaint. how can i use that as my chief complaint? any help will be greatly appreciated.

Ivonne


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## LOUISE SLACK (Aug 19, 2010)

If this is a new problem and additional work up was planned ( U/S) then you have your number or diagnosies/treatment options.  If you use the Marshfield tool or something similar 4 points, 
1 point for data. I would go with low risk unless the obese patient has problems like HTN, High blood sugar or other obesity realated illness (systemic syptoms) that will require additional monitoring/treatment.  She may become a moderate to high risk at the preganancy progresses but at this visit nothing is documented, besides BMI, to indicate additional provider work, like referral to dietician, or counseling for weight loss etc.
BUT it is my understanding that OB visits are not separately billed and ar bundled with the delivery??


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## Ivonne C. (Aug 20, 2010)

thank you Louis,
Thank you for your help, you helped clarify things a little bit for me.Yes it is my understanding that OB visits are not billed seperately, but this is the patients first visit and the doctor is confirming her pregnancy. Wouldn't that be billable? I appreciate any help.

Ivonne


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