# new problem with workup



## smaher82 (Jun 15, 2012)

Hi,

  We had an auditor come in and say any new problem with work up is considered moderate MDM. An ex given was ankle pain r/o fracture sent for xray. 

Im just trying to figure out how that adds up on the points. Where does it fall on the highest risk table? Acute complicated injury?

We have pts come in and when they have a new pain they  sometimes send them for an xray does that equal moderate MDM?

Thank you!


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## adri3421 (Jun 15, 2012)

When determining MDM you are looking at 3 things: Diagnosis options, data reviewed, and risk. 2 of these 3 element must be on a "moderate" level to determine your overall MDM.

The auditor is only referring to diagnosis options in your example above.....and actually any significant new problem with NO additional workup is falls under "moderate/multiple" MDM. A significant new problem WITH additional workup falls under "high/extensive" MDM.

I would only consider ankle pain alone to be an uncomplicated injury......falling under low on the risk table. But if the xray confirmed an actual fracture I would consider it a complicated injury falling under moderate risk. 

Hope this helps


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## smaher82 (Jun 15, 2012)

Thank you for your reply. What about if they have prescription mgmt? ( flexeril, tramadol) would that make it Moderate MDM?  I know my providers will ask so I wanna be prepared.


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## adri3421 (Jun 18, 2012)

Im not sure what region you are in but our medicare contractor, cahaba, does consider prescription drug management to be moderate risk, even if its just a refill with no changes. But you would probably want to check with your carrier.

https://www.cahabagba.com/part_b/education_and_outreach/faq_mr.htm#2


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