# MDM points: established problem, worsening...



## amexnikki23 (Aug 13, 2015)

Hey all, when scoring for MDM, do you consider ALL established problems, worsening equal? For instance...

ongoing depression w/anxiety: pt comes in to start a new med. same issues, anxiety, depression, mood swings, etc. no suicidal ideation, anehdonia, etc. new meds Rx'd 

versus...

asthma exacerbation of chronic asthma. breathing tx given, refill meds, etc. would this now be considered an acute episode, new condition, etc.?

versus...

hypertension follow-up, slightly raised BP, refills given


ALL THESE ALL 2 POINTERS WHEN IT COMES TO THE PROBLEM POINTS??

Thanks!


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## CatchTheWind (Aug 20, 2015)

It's interesting that you, as a coder, are being asked to make that assessment; our EMR asks the providers to state what the status of the problem is (ie: improving, stable, inadequately-controlled, or worsening).  I didn't know that in other practices the coders are expected to make that assessment.

If I were required to make that assessment, I would go with two points for the first two conditions, as they both seem to be inadequately controlled; the hypertension, on the other hand, seems to be stable, so just one point.


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## LLovett (Aug 20, 2015)

I would only give 1 point for each of those.

You cannot make the determination of worsening, the provider must state it. For all we know those are all improvements for those patients since their last visit.

If not clearly stated otherwise then you must default to stable.

When it is stated, all established problems worsening are counted as 2 points, regardless of the severity.

It's not what you are treating, it's where you're at in treatment.

As far as your asthma diagnosis example, I would call it established. 

Just my two cents,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC


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## CatchTheWind (Aug 24, 2015)

I like your answer.  I did not feel comfortable with the idea of a coder making the determination, and now that you've said so, I would change my answer and agree with you that if the provider doesn't say that it's worsening or inadequately controlled, then it isn't.  

Thanks!


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## Cynthia Hughes (Aug 25, 2015)

Though some EHRs may capture exact terminology from the Marshfield Clinic E/M worksheet, there is no requirement that physicians use that language. It is important that coders recognize that an exacerbation is a worsening and a sign that asthma is not sufficiently controlled, that a patient requiring a change in medication for a chronic problem is an indication that the problem is not stable or improving (with exceptions for changes due to formulary requirements or patient wanting the latest advertised med), and that it may be necessary to ask the physician or provider when you are not sure. The severity of a worsening problem is captured in the table of risk. If you decide that an asthma exacerbation is not a worsening problem, you may unfairly reduce the overall level of MDM for management of a complex chronic condition. I am glad you asked this question and hope that it encourages all coders to make the effort to research and learn the indications of stable vs. worsening and many of the other complexities of connecting documentation to coding.


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## CatchTheWind (Aug 25, 2015)

Are you stating that the provider does not have to document his observation that the condition is worsening or inadequately controlled in order for it to be billed as such; the coder can make this decision based on the narrative?  

If so, what is your source for this?  Thanks!


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## LLovett (Aug 25, 2015)

I have to disagree with you Cynthia but I am certainly open to changing my mind if you have official source documentation to support this.

Currently, I am auditing hospitalist charges. So I see the patients entire stay. Everyday they are assessing things like "COPD exacerbation", even when they are discharging the patient. Based on what you have stated this problem would qualify as worsening even when the documentation supports they are improving.

It is a good discussion though.

Laura, CPC, CPMA, CPC-I, CANPC, CEMC


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## Cynthia Hughes (Aug 25, 2015)

First, let me say that I would always look at the whole note for the encounter. The examples given such as asthma exacerbation with treatment at the encounter are clearly worsening problems whereas daily visits with a diagnosis of COPD exacerbation may or may not show worsening or failure to improve and the overall documentation will guide on those notes (eg, is the physician making new decisions to improve management of the condition or stating that no further improvement is expected).

The E/M documentation guidelines state, "For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation." 

My intent is to say that certain terms imply worsening and that if the remainder of the documentation supports this (eg, the problem is an exacerbation requiring immediate or new treatment, not controlled with current management or treatment, etc.), the documentation supports a worsening problem or one that is failing to improve with current management. 

Here is an article this topic that may be helpful. http://www.racmonitor.com/rac-enews/1804-giving-clarity-to-the-ambiguity-of-e-m-services.html

Best wishes.


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