# Help please!! Counting Problem Points in the MDM-New Patient



## donnalynn (Jun 21, 2013)

Hello All,

I would like your input please.  There is a difference of opinion regarding the scenario below on whether you can count "new problem, with no additional work-up planned" and ALSO count "new problem, with additional work-up planned" on the same encounter.  The example is at the bottom but I included the details of the chart for review.  

CC: “Shortness of breath.”

HPI: Patient is a 68 year old male with a history of CHF who presents with SOB. He states this problem began about two weeks ago. The shortness of breath may occur at rest or with exertion. The timing is described as intermittent. His breathing is worse when laying flat. He has noticed his shortness of breath is often associated with worsening lower extremity swelling. He states he has a history of heart disease, but had a “negative” nuclear stress test approximately one year ago. 

Medications

Atenolol 25 mg PO QD
Glyburide 5 mg PO BID
Lisinopril 10 mg PO BID
Atorvastatin 20 mg PO QD

PMH : per HPI, plus osteoarthritis and dyslipidemia

ROS :Complete ROS was performed and documented and was positive for intermittent lower extremity edema and easy bruising. For more details, please refer to the ROS questionnaire with today's date located in the chart.

FH: Mother died in her 80s of “old age”; father at age 72 of pneumonia. The patient has three grown children in good health.

SH: The patient has been married for 45 years. He denies tobacco or alcohol abuse and continues to drive himself around.

Physical Exam

Vitals: 130/80, 88, 98.6
General appearance: NAD, conversant 
Eyes: anicteric sclera, moist conjunctiva; no lid-lag; PERRLA
HEENT: AT/NC; oropharynx clear with MMM and no mucosal ulcerations; auditory canals patent with pearly TMs normal hard and soft palate 
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy 
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules
Psych: Appropriate affect, alert and oriented to person, place and time

Labs: HGBA1c 6.8; BUN 25, creatinine 0.8; LDL 88, HGB 12
Assessment
1.	Significant shortness of breath
2.	Well controlled HTN
3.	Optimally controlled NIRDM
4.	Stable dyslipidemia
5.	Stable CAD
Plan
1.	Will add Lasix 40 mg PO qd
2.	Will contact his former physician to obtain records of recent stress test
3.	Will check a CXR today to rule out pneumonia
4.	Will order an ECHO as well to quantify his EF
5.	Return visit next week
6.	Will check repeat HGBA1c, CBC, and renal profile
7.	Will also check LFTs since patient is on statin medication
8.	Will also check spot microalbumin/creatinine



*Problem Points:* 

In the example above, the clinical problems would be scored as follows:

Problems	                                                                              Points
Self-limited or minor (maximum of 2)	                                 	
Established problem, stable or improving	                                 	
Established problem, worsening	                                                 	
New problem, with no additional work-up planned (maximum of 1)	   -    * X	* 
New problem, with additional work-up planned	            -            *X* 


*Total Problem Points = 7 

Three points are scored for the "new" problems of HTN, diabetes, dyslipidemia, CAD for which no further workup is planned (max of one problem for this category). Four points are given for the "new" problem of CHF because further workup is ordered. This adds up to a total of seven problem points.*


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## donnalynn (Jun 21, 2013)

Is this accurate?? Anyone?? Thank you in advance!! 



*Problem Points:* 

In the example above, the clinical problems would be scored as follows:

Problems	                                                                              Points
Self-limited or minor (maximum of 2)	                                 	
Established problem, stable or improving	                                 	
Established problem, worsening	                                                 	
New problem, with no additional work-up planned (maximum of 1)	   -    * X	* 
New problem, with additional work-up planned	            -            *X* 


*Total Problem Points = 7 

Three points are scored for the "new" problems of HTN, diabetes, dyslipidemia, CAD for which no further workup is planned (max of one problem for this category). Four points are given for the "new" problem of CHF because further workup is ordered. This adds up to a total of seven problem points.*


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## MikeEnos (Jun 21, 2013)

Absolutely, this seems like a complex case with many diagnoses, so it's not surprising that you have an extensive amount of diagnosis (MDM-A) points.  I agree with your allocation of diagnoses as _*New problem w/o add'l w/u*_ and *New problem w/ add'l w/u planned*.


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## donnalynn (Jun 21, 2013)

MikeEnos said:


> Absolutely, this seems like a complex case with many diagnoses, so it's not surprising that you have an extensive amount of diagnosis (MDM-A) points.  I agree with your allocation of diagnoses as _*New problem w/o add'l w/u*_ and *New problem w/ add'l w/u planned*.



That is what I thought!  Thank you very much for your response and making it clear!


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## andersee (Jun 21, 2013)

The highest # of points in this category (diagnosis) is 4. Achieving 7 does not up the LOS in-and-of-itself. You'd need to meet it one of the other two areas of MDM.


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## MikeEnos (Jun 22, 2013)

Of course not.  This entire discussion is based on the MDM-A category of *diagnosis points*.  There is a big difference between 3 and 7.  When calculating the overall complexity of the Medical Decision Making, that could be the difference between Moderate and High complexity.  Donnalynn's concern is that there is a maximum of 1 *New problem w/o add'l w/u * -but since she had another *New problem with add'l w/u planned* she gets credit for an extensive amount of diagnosis points.


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## andersee (Jun 25, 2013)

Perhaps our carrier is different than yours. Our carrier allows up to 4 pts for Diagnosis and we must meet or exceed the same level in two of the three areas (Data, Risk). So achieving 7 pts does not increase our level of service. That's lucky that yours looks at it that way but ours does not.


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## MnTwins29 (Jun 25, 2013)

I didn't see the question as one of the level of MDM - only the number of points in the Diagnosis/Problems section of MDM - section A.    So the answer about what carriers need for a high level of MDM is moot.  And for the record - agree with Mike and donnalynn that there are 7 points for section A.   Maybe Mike's answer when he said a "complex case" was the source of confustion?   I didn't take that as he was talking about the level of MDM - just an overview of the entire case.


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## donnalynn (Jun 25, 2013)

Yes, my question was for the number of points in the Diagnosis/Problems section of the MDM-section A.  There was some conflict as to whether you could count New Problem* without* additonal work up AND count New Problem *with* additonal work up planned on the same encounter so that is why I asked the question *just* about this section.  Thanks again for everyones input!!


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