# Needing help with OB visit



## Ivonne C.

Hi everyone, Im having a little bit of an issue with a chart i am auditing for an OB/GYN. The patient is coming for her first OB visit for a complete physical (which would normally fall under Global), but the physician does not hear a fetal heart beat. she is only 7 1/2 weeks along, she states she is not having any symptoms other than those associated with being pregnant such as breast tenderness and fatigue. the physician put DX 640.03- threat to abort. In the plan the Physician orders labs and a cytopathology.

-(side note) the Dr. ordered a Suction D&C 6 days later.

My question is in the risk assesment portion of the MDM what would this classify as? Moderate or High? My colleague suggests "High" but I am on the fence, since the patient is not having any severe problems assoc. with the miscarriage.

Her history and exam were both comprehensive so the MDM is the decideron either a 99204 or 99205

Any help would be appreciated 

Ivonne, CPMA


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## preserene

Yes Ivonne, it is indeed it is the physician's job to give the MDM. Since you brought it to the thread  for evaluation , I come out with my opinion . See if it could help -

The key sentences:
 1.no fetal heart beat (should have been through US).
 2.Physician documented threatened abortion. (No bleeding; no mention  about Os opened or not) 
 3.Lab tests and cytopath ordered-which infers the patient is not in immediate danger but lab tests needed for later evaluation of sequlae of threated abortion /or missed abortion going for threated abortion and for treatment modalities
(All these documentation made after Comprehensive History and Comp examination.)
4.Time is requested or bought by the Physician to plan a definitive plan of D&C /Suction curettage at a later date.

MDM for this would go for moderate.

It cannot be taken down to a lower level 'LOW' because danger cannot be ruled out.
It cannot be upgraded to high because it is not critical at this stage and it could continue to be at the optimal level of risk or late turn out to be critical, if she starts bleeding or the lab test like coagulation profile are not favorable. I am sure physician would have given a counseling to return any time if she starts bleeding.


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## btadlock1

Ivonne G. said:


> Hi everyone, Im having a little bit of an issue with a chart i am auditing for an OB/GYN. The patient is coming for her first OB visit for a complete physical (which would normally fall under Global), but the physician does not hear a fetal heart beat. she is only 7 1/2 weeks along, she states she is not having any symptoms other than those associated with being pregnant such as breast tenderness and fatigue. the physician put DX 640.03- threat to abort. In the plan the Physician orders labs and a cytopathology.
> 
> -(side note) the Dr. ordered a Suction D&C 6 days later.
> 
> My question is in the risk assesment portion of the MDM what would this classify as? Moderate or High? My colleague suggests "High" but I am on the fence, since the patient is not having any severe problems assoc. with the miscarriage.
> 
> Her history and exam were both comprehensive so the MDM is the decideron either a 99204 or 99205
> 
> Any help would be appreciated
> 
> Ivonne, CPMA



The annoying thing about MDM is that it's subjective. Differing perspectives produce different results. Personally, I would have rated this as high, although I definitely see the logic supporting moderate. This could be WAY off base, but I believe that the patient's condition is more complicated than just "healthy" or "sick". The health of the pregnancy becomes nearly equally significant for an OB patient's risk, since a failed pregnancy can pose a huge array of problems for the mother, from medical to psychiatric. The nature of the presenting problem would be high, because the healthiest outcome would be hearing a heartbeat on schedule, to indicate a healthy, on track, pregnancy. The exact opposite occurred, meaning there's the possibilty of an extreme risk to the health of the pregnancy, which could in turn, pose a huge threat to the mother's health. This, in my opinion, would be a new condition with acute exacerbation and an uncertain prognosis, and a high potential for serious morbidity and/or mortality. It's not necessarily the apparent risk, but the potential risk that would complicate the physician's decision making. Could this reasonably lead to the discovery of a serious condition, requiring emergency intervention? What are the potential consequences in the worst case scenario, since the physician has no history to reference?

I'm inexperienced in this area, and that might show , but in my commercial claims experience, that is how I would defend a 99205's MDM in an appeal. I'd like to know other people's views on this to see if I should adjust my point of view. Maybe I'm giving too much credit for the difficulty in decision making for this kind of situation...


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## preserene

*Number of diagnosis*: * limited-*  threatened Abortion.
*Amount &/or complexity of  data*:  the normal routine tests usually done for this diagnosis are urinanalysis,(any method) CBC, and if at all needed, special test- Coagulation Profile 3-4 tests –*MODERATE*.(with no complex tests mentioned or documented)
*Risks & Morbidity and mortality *with respect to the mother (in this case at this weeks of pregnancy and with threatened abortion with no bleeding or any other relevant  symptom associated with the diagnosis:  *Moderate complexity.* 
On clinical perspectives also,  not only me, any ObGyn Physician  would place her at low level of risk at this stage of encounter  with the available findings as threated Abortion with no symptom at all, in the absence of any other complexity too,( for eg no coagulation failure, or signs of DIVC and so on and so forth , not worth considering at this juncture).
*To sum up, the type of Decision Making needs 2/3element to be met or exceeded -  so MDM  is Moderate. *
Social, socioeconomical condtion, emotional, psychological factors  or,comorbidity/underlying diseases in and of themselves are not considered in selecting  a level of E/M services unless their presence significantly increases the complexity of the medical decision making. 
Medical and clinical aspect of decision making also, the points you put forth are not going to increase the complexity of medical decision making by the treating OBGYN on the obstetric point of management and treatment modalities.
The physician gives a subsequent  follow up  with the optimal risk of the outcome only to be taken up for treatment at the following visit.


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## mitchellde

I agree with Brandi on this one.  It is MDM is subjective and as long as you have good sound reasoning to support your assignment of the three components then subsequently the level of MDM then there will be no problem.  If the payer asks for the record or downcodes the reimbursement then you can use your rationale in your appeal and you should be successful.  I liked Brandi's approach to the issue and she could very well support the high level decision making with that rationale.  The incorrect thing is to assume there is only one right approach to a problem and to not have an approach at all.  If you always use the criteria in the same way and never let any one scenario or individual sway your assessment of the documentation then you should do well.  Either of you can be correct on this and without seeing the physician's documentation it would be hard to say which one, however the person that posted the question now has 2 ways to view the documentation and should be very able to make the right decision.


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## Ivonne C.

I appreciate all the responses to this question. I do see both ways on how to approach the risk assesment issue. That is one of the toughest sections for me to adjust when auditing, since as you can see can sometimes go either way. I will take this information with me to help with future audits. 


Thank you guys 
Ivonne, CPMA


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## FTessaBartels

*Moderate*

All indications - that have been reported in the original post - are that the mother is feeling just fine, other than the "routine" effects of pregnancy (fatigue and sore breasts).  What happened six days later is immaterial to the decision making/ risk of THIS visit.  At THIS visit it is an undiagnosed new problem with uncertain prognosis. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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