# Question about MDM?



## asasands (Sep 28, 2011)

If I follow the 95 guidelines......do I need to add up points for the MDM?

I work for general surgeons, majoritie of our cases is for breast, colon, gallbladder and hernia surgeries.

If a patient comes in for Gallbladder, doesn't have any other chronic dx, but the us needs to be reviewed by the physician, surgery is talked about ect, do you consider this to be of moderate complexity.  The reason why because the physicians are surgeons, the risk involved with surgery, they at least have one chronic condition...the pain, bloating ect.

Assuming the HPI, ROS and PE qualifiy with the above information do you think I can use either a 99204 or 99244?

I know everybody talks about points, but I don't think I need to used them with the 95 do I?

Thanks for any help,

Stacey


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## rthames052006 (Sep 28, 2011)

asasands said:


> If I follow the 95 guidelines......do I need to add up points for the MDM?
> 
> I work for general surgeons, majoritie of our cases is for breast, colon, gallbladder and hernia surgeries.
> 
> ...



I would think you need to add up your points, the problem(s) these patients are coming in to see your surgeons are *NEW TO THE PROVIDER *

Since you are talking new patient and consult codes you do need all 3 key components ( history, exam and MDM) to qualify for any level in those categories.


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## asasands (Sep 28, 2011)

But what I am confused about is how do I add up the MDM....A complete ROS and PE and HPI was done, but I don't know if the MDM part of it qualifies.  How do I know what level of MDM to use?


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## rthames052006 (Sep 28, 2011)

Not sure who your MAC is but mine is Highmark Medicare.  I've attached a link to their e/m scoresheets, there you will find the 3 sections that you'll need to tally the MDM area.  When you click on the link pick the 1st score sheet 1995.

https://www.highmarkmedicareservices.com/em/scoresheets.html


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## FTessaBartels (Oct 4, 2011)

*I'll try to help*

Your question is a little "fuzzy" - probably because you do not clearly understand E/M coding.  But I'll try to help....

As Roxanne stated, you WILL need to determine your level of MDM, which is comprised of TWO out of the THREE elements - problem points, data points and level of risk.

PROBLEM POINTS - the first time the patient comes to your surgeon with the gallbladder issue it is a NEW PROBLEM.  This is either worth 3 points or 4 points, depending on whether additional work-up is required.  If the doctor is going to order an ultrasound, for example, that is additional work-up.  If the patient also has diabetes and the doctor is going to ask for a consult from her endocrinologist before proceding that is ALSO additional work-up.  

DATA POINTS - ordering or reviewing lab tests is work 1 point. Ordering or reviewing tests in the radiology section of CPT is worth 1 point (e.g. ordering that US).  Ordering or reviewing tests in the medicine section of CPT is worth 1 point (e.g. if he ordered an EKG).
If the surgeon actually personally reviews the films from the ultrasound or the EKG tracing (vs reviewing the REPORT from the radiologist or cardiologist), then that is worth 2 points. 

LEVEL OF RISK - gallbladder surgery is major surgery.  This is also ELECTIVE major surgery (i.e. it is not being done on an emergency basis like a burst appendix, for example, would be).  So it it either MODERATE risk - if the patient has *no *identified risk factors (i.e. the patient does not have any co-morbidities like DM or on blood thinners or immune suppressed or ....);  or it is HIGH risk if the patient DOES have *identified* risk factors.   Please note the word "Identified" ... the surgeon must clearly document the patient's risk factors to get a "high" level of risk.

You mention the patient has at least "one chronic condition - pain, bloating, etc"  These are examples of SYMPTOMS, NOT a chronic illness. 


FINALLY ... you need two out of three to arrive a the final level of risk. So let's say you have 3 problem points, 1 data point, and high level of risk .... you'd still only get a Moderate MDM, because you'd need either 4 problem points OR 4 data points to match your high level of risk to get a High MDM.   I'd say that most of your straightforward gallbaldder or hernia surgeries will be Moderate risk, unless the patient has DOCUMENTED co-morbidities. 


Hope that helps.

F Tessa Bartels, CPC, CEMC


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