# Moderate Complexity or High Complexity MDM



## kathymoon

I have just begun some training with our Hospitalists, who currently are not coding their visits.  We have a CPC who doing the actual coding at this time.  So as I review their records I am curious how you would decide the Medical Decision Making on the following case.  There seems to be some discrepancy between my code and the CPC's.  I'll keep it as brief as possible.  This is  for the admission day.

Reviewed CT-scan of abdomen (showed bilateral hydronephrosis)
History of previous kidney stones.

1.  Obstructive kidney stone, bilaterally
a) Admitting physician spoke directly to urologist for his recommendations and planning stent placement in the morning.
b) IV fluids and IV Dilaudid for pain
2.  Acute renal failure probably secondary to hydronephrosis
3.  Questionble inflammation around the appendix.  
a) Surgeon being consulted regarding appendix

There is a Comprehensive history and Comprehensive Exam.


So who says 99222 and who says 99223?   

And thanks in advance for the feedback.


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## Robyn07

kathymoon said:


> I have just begun some training with our Hospitalists, who currently are not coding their visits.  We have a CPC who doing the actual coding at this time.  So as I review their records I am curious how you would decide the Medical Decision Making on the following case.  There seems to be some discrepancy between my code and the CPC's.  I'll keep it as brief as possible.  This is  for the admission day.
> 
> Reviewed CT-scan of abdomen (showed bilateral hydronephrosis)
> History of previous kidney stones.
> 
> 1.  Obstructive kidney stone, bilaterally
> a) Admitting physician spoke directly to urologist for his recommendations and planning stent placement in the morning.
> b) IV fluids and IV Dilaudid for pain
> 2.  Acute renal failure probably secondary to hydronephrosis
> 3.  Questionble inflammation around the appendix.
> a) Surgeon being consulted regarding appendix
> 
> There is a Comprehensive history and Comprehensive Exam.
> 
> 
> So who says 99222 and who says 99223?
> 
> And thanks in advance for the feedback.



Hi Kathy...

Both items 2 and 3 I would not include in as they are not definitive. I would caution on the side of the 99222.

Robyn M Alvarado, CPC


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## MnTwins29

kathymoon said:


> I have just begun some training with our Hospitalists, who currently are not coding their visits.  We have a CPC who doing the actual coding at this time.  So as I review their records I am curious how you would decide the Medical Decision Making on the following case.  There seems to be some discrepancy between my code and the CPC's.  I'll keep it as brief as possible.  This is  for the admission day.
> 
> Reviewed CT-scan of abdomen (showed bilateral hydronephrosis)
> History of previous kidney stones.
> 
> 1.  Obstructive kidney stone, bilaterally
> a) Admitting physician spoke directly to urologist for his recommendations and planning stent placement in the morning.
> b) IV fluids and IV Dilaudid for pain
> 2.  Acute renal failure probably secondary to hydronephrosis
> 3.  Questionble inflammation around the appendix.
> a) Surgeon being consulted regarding appendix
> 
> There is a Comprehensive history and Comprehensive Exam.
> 
> 
> So who says 99222 and who says 99223?
> 
> And thanks in advance for the feedback.



Agree with Robyn - using only the obstructive kidney stone dx, I am assuming the MD knows of this problem - would be two points.  Even though she mentioned to not use #2, I would add the hydronephrosis as it is mentioned there and in the review of the CT scan documented by the MD.  That give 3 problem points.   Data - one for reviewing the CT scan, two for speaking with urologist for a total of three.   Risk - at best, moderate for the stent placement if that is decided to be done.  Low certainly for the IV.   In any case, that translates to moderate MDM at best, which would result in 99222.

Just my $0.02

Thanks.


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## kathymoon

This is a new problem to this physician.  This is the first time he has ever seen this patient.  So with new problem, is the stent not considered additional workup?  Or consulting the general surgeon regarding the inflamation?  Does this not bring the treatment options up to a 4?


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## MnTwins29

kathymoon said:


> This is a new problem to this physician.  This is the first time he has ever seen this patient.  So with new problem, is the stent not considered additional workup?  Or consulting the general surgeon regarding the inflamation?  Does this not bring the treatment options up to a 4?



Even with this information and we give 4 points for that portion, that still leaves three data points and moderate risk.   That is still moderate MDM as you need two of three.   The one other way I could see getting this upgraded is if the acute renal failure can be confirmed, as it is not clear in the documentation supplied here.  If that is the case, then the risk can be bumped up to high - ARF can certainly be considered a threat to bodily function - and then you get high MDM and 99223.


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## kimsggl

kathymoon said:


> I have just begun some training with our Hospitalists, who currently are not coding their visits.  We have a CPC who doing the actual coding at this time.  So as I review their records I am curious how you would decide the Medical Decision Making on the following case.  There seems to be some discrepancy between my code and the CPC's.  I'll keep it as brief as possible.  This is  for the admission day.
> 
> Reviewed CT-scan of abdomen (showed bilateral hydronephrosis)
> History of previous kidney stones.
> 
> 1.  Obstructive kidney stone, bilaterally
> a) Admitting physician spoke directly to urologist for his recommendations and planning stent placement in the morning.
> b) IV fluids and IV Dilaudid for pain
> 2.  Acute renal failure probably secondary to hydronephrosis
> 3.  Questionble inflammation around the appendix.
> a) Surgeon being consulted regarding appendix
> 
> There is a Comprehensive history and Comprehensive Exam.
> 
> 
> So who says 99222 and who says 99223?
> 
> And thanks in advance for the feedback.



High Complexity is over coded and  billed alot, and does not always fall under such conditions. .
With high complexity we need to have a severe exacerbation of a chronic problem; or acute illness which threatens life or bodily  function to quialfy,  data r'vd would have to be extensive to reach the threshold for high complex MDM.  The is more apt to happen in intial encounters.


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## adwood68

I feel that the decision making supports 99223. Number of treatment options I give it 4 points for new problem with additional work up. For amount and or complexity of data I give it 4 points (2 for personally reviewing the CT scan and 2 for discussing case with another health care provider). For the risk table I give it high for the parenteral controlled substances.


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## adwood68

*Just to clarify*

I gave him four points in table A because it was a new problem to the provider and the additional work up was ordering the CT and ordering the consult.


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## Tonyj

MnTwins29 said:


> Even with this information and we give 4 points for that portion, that still leaves three data points and moderate risk.   That is still moderate MDM as you need two of three.   The one other way I could see getting this upgraded is if the acute renal failure can be confirmed, as it is not clear in the documentation supplied here.  If that is the case, then the risk can be bumped up to high - ARF can certainly be considered a threat to bodily function - and then you get high MDM and 99223.



I beg to differ as to the confirmation of ARF. As in the A/P ARF is implied, it's just not definitive as to if it is "due to" hydonephrosis. The pt is in acute renal failure and has hydronephrosis.  Which would substantiate the 99223.

I wouldn't use #3 as it is not definitive.

Reviewed CT-scan of abdomen (showed bilateral hydronephrosis)
2. Acute renal failure probably secondary to hydronephrosis
3. Questionble inflammation around the appendix.


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## mhstrauss

*I have a similar question*



MnTwins29 said:


> Even with this information and we give 4 points for that portion, that still leaves three data points and moderate risk.   That is still moderate MDM as you need two of three.   The one other way I could see getting this upgraded is if the acute renal failure can be confirmed, as it is not clear in the documentation supplied here.  If that is the case, then the risk can be bumped up to high - ARF can certainly be considered a threat to bodily function - and then you get high MDM and 99223.




I'm going to piggyback onto this thread, as my question is very similar to this one about "additional workup".  Is "sending the patient to a surgeon" considered additional workup? If yes, does it matter whether or not the originating MD states it to be a "consult" vs "referral"?  In my situation, one of my Neurologists saw a patient in clinic recently for Meningioma found by another MD.  Neurologist's impression is "meningioma; I recommend Neurosurgical consultation".  No other diagnostic tests were ordered, as all scans needed had already been performed.  Does this justify the additional workup for 4 points in the Number of Diagnoses/Treatment Options?

TIA!!


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