# MDM, diagnosis points



## kmartinez (Sep 14, 2018)

I would love some input as I have been told two different things and no research online has helped  

 This is regarding the MDM, Diagnosis/Management points. 

 If doctor states at the end of his I&P, " I have considered the following conditions, being managed by patient's other providers, during this visit: anxiety and fatigue."  -- Can these count as two problem points, one for anxiety and one for fatigue, *or does doctor need to state that he has considered the conditions and that they are stable *(or whatever the conditions status may be). 

I appreciate any input regarding this. New to auditing and little nervous about it  

TIA
KAM


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## Chelle-Lynn (Sep 14, 2018)

If this is the entire statement related to these conditions, than I would recommend that you query the provider for additional clarification.  To be considered for Medical Decision Making (MDM) the documentation requires a little more support.  You are correct that statement to effect of "stable" would be needed to determine that the physician managed or evaluated the status of the condition.


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## kmartinez (Sep 14, 2018)

Great! Thank you for your response.


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## sparkles1077 (Sep 14, 2018)

You would also need to see that each problem is treated or managed in some way.

Per 95 guidelines:
DG:  The initiation of, or changes in, treatment should be documented.Treatment includes a wide range of management options including
patient instructions, nursing instructions, therapies, and medications.

For example:

Stable anxiety - Continue 0.5 mg xanax daily
New fatigue:  Check CBC, TFTs, ESR


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## Pathos (Sep 17, 2018)

sparkles1077 said:


> You would also need to see that each problem is treated or managed in some way.
> 
> Per 95 guidelines:
> DG:  The initiation of, or changes in, treatment should be documented.Treatment includes a wide range of management options including
> ...



Agreed, if the provider is just giving you a laundry list of the patient's problems, but did not address each problem, then I would be hesitant to count them towards anything.

Querying the provider when something is unclear is recommended, just be careful you don't ask leading questions.


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## TTcpc (Sep 21, 2018)

kmartinez said:


> I would love some input as I have been told two different things and no research online has helped
> 
> This is regarding the MDM, Diagnosis/Management points.
> 
> ...



Hello, 

I agree from what you have posted that a query to the provider is necessary.  It may be that he/she has "considered" the anxiety and fatigue as it may affect how the condition that he/she is treating the patient for by exacerbating it or maybe the treatment for the anxiety and fatigue contradicts the planned treatment for the condition he/she is treating.  All of this being said, the provider should be documenting this thought process within the note.

I hope this helps!


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