# Opinion need for risk in MDM



## TTcpc (Jul 17, 2018)

Hello,
I am working with a pediatric specialty group and would like some opinions regarding how to "grade" this risk for the MDM. The patients are in the GI clinic as new patients often with reflux, projectile vomiting, and fussiness after feeding as the primary complaints from the parents.  The providers aren't doing any additional work-up, not ordering any labs/rad, and usually just adjusting formula, having the mother change her diet if breastfeeding sometimes will have them start Zantac for possible GERD.  So I'm getting new patient/no additional work-up = moderate; no labs/rad/records reviewed = straightforward.  The risk is were I'm getting myself confused..no Rx, feeding recommendations so I'm hitting low risk OR if I consider it a chronic problem (most have had it since birth or at least a month or more without improvement) with mild exacerbation I would have moderate risk OR is the infant too young for it to really be considered a "chronic" condition and I consider it acute uncomplicated illness???  

I have a feeling I'm overthinking this, but it could honestly make the different in the CPT level between the Low and Moderate MDM.  

Thank you!


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## Pathos (Jul 17, 2018)

The Medical Decision Making portion of an E/M visit, is without a doubt the most subjective part, and often the hardest to audit. However, CMS has given us some guidance on how to distill these components and turn them into AMA CPT codes.

First, lets look at the Presenting Problems for *Low* and *Moderate* Risk:

*Low*:
_• Two or more self-limited or minor problems
• One stable chronic illness (for example, well controlled hypertension, non-insulin dependent diabetes, cataract, BPH)
• Acute uncomplicated illness or injury (for example, cystitis, allergic rhinitis, simple sprain)
_
*Moderate*:
_• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain prognosis (for example, lump in breast)
• Acute illness with systemic symptoms (for example, pyelonephritis, pneumonitis, colitis)
• Acute complicated injury (for example, head injury with brief loss of consciousness)_

MedlinePlus also defines chronic vs. acute this way:

_"Acute conditions are severe and sudden in onset. This could describe anything from a broken bone to an asthma attack. A chronic condition, by contrast is a long-developing syndrome, such as osteoporosis or asthma. Note that osteoporosis, a chronic condition, may cause a broken bone, an acute condition. An acute asthma attack occurs in the midst of the chronic disease of asthma. Acute conditions, such as a first asthma attack, may lead to a chronic syndrome if untreated."_


You mentioned that the "_new patients often with reflux, projectile vomiting, and fussiness after feeding as the primary complaint_". Based on your information and the above references, I would be hesitant to designate any of the three complaints as chronic after just one month. I would lean towards acute problems. Some experts argue of the timeline of acute vs. chronic, but I think you need to look at the source of the problem and if it's likely to be chronic in the foreseeable future. Also, if the problem has been going on for a while with little chance of resolving, then it's likely to be chronic as well.
That leads us to "_Acute uncomplicated illness or injury_" vs. "_Acute illness with systemic symptoms (for example, pyelonephritis, pneumonitis, colitis)_". While reflux, vomiting and fussiness are all something that would require medical management, I would place them under "Acute uncomplicated illness or injury", as I would not put them in the same group as pyelonephritis, pneumonitis or colitis, and thus give the visit a Low Risk.


Hope that helps you.


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## Cynthia Hughes (Jul 18, 2018)

*risk in pediatrics*



twtcpc said:


> Hello,
> I am working with a pediatric specialty group and would like some opinions regarding how to "grade" this risk for the MDM. The patients are in the GI clinic as new patients often with reflux, projectile vomiting, and fussiness after feeding as the primary complaints from the parents.  The providers aren't doing any additional work-up, not ordering any labs/rad, and usually just adjusting formula, having the mother change her diet if breastfeeding sometimes will have them start Zantac for possible GERD.  So I'm getting new patient/no additional work-up = moderate; no labs/rad/records reviewed = straightforward.  The risk is were I'm getting myself confused..no Rx, feeding recommendations so I'm hitting low risk OR if I consider it a chronic problem (most have had it since birth or at least a month or more without improvement) with mild exacerbation I would have moderate risk OR is the infant too young for it to really be considered a "chronic" condition and I consider it acute uncomplicated illness???
> 
> I have a feeling I'm overthinking this, but it could honestly make the different in the CPT level between the Low and Moderate MDM.
> ...



I feel you must look at these case by case. In neonates, these symptoms carry a higher risk because of the risks of dehydration and inadequate nutrition. Zantac in pediatric dosage is prescription drug management (moderate risk). A diagnosis of reflux is lower risk than a diagnosis of GERD. Other factors that may increase risk are history of premature birth, onset of vomiting after 6 months of age, and any comorbidities. It may be helpful to discuss with the physicians and obtain opinions on which factors fall into low risk (e.g., change in feeding, position after feeding) and which are moderate (e.g., order for Zantac, diagnosis of GERD).

I hope that helps.

Cindy


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