EM Coding Alert

Figuring out the medical decision making (MDM) on a service can be difficult so why not lean on a developed point-based system that takes the sting out of he process.

 

Use this example with the Marshfield point system that uses the three components of the MDM to come to the final type of MDM.

 

Example: A 38-year-old female established patient comes into your practice to see her physician. She presents with ankle pain and swelling she’s had for the past four days. There is some bruising around the left ankle and walking is painful. The patient states she fell during soccer practice and her ankle has hurt since then. She has not had any fever or additional muscle pain. She has sprained this ankle twice before.

 

Your physician diagnoses an acute ankle sprain and orders an x-ray. He does not perform the x-ray in his office, but is able to send the patient for x-ray and review and provide the results on the same day. The imaging shows no fracture per radiology interpretation. The doctor prescribes a pain killer and anti-inflammatory for 10 days. He stabilizes the ankle with a bandage wrap and suggests ice for 10 minutes three times per day. He tells his patient no soccer until re-evaluation and to come back if symptoms worsen.

 

Component 1: Diagnosis and Treatment Options

 

 

1 point = minimal, 2 points = limited, 3 points = multiple, 4 points = extensive

 

Component 2: Reviewed or Ordered Data

 

 

0-1 point = minimal, 2 points = limited, 3 points = multiple, 4 points or more = extensive

 

Component 3: Level of Risk

MDM result: Looking at the elements, you have extensive diagnosis and treatment options, minimal data complexity, and moderate risk. The MDM is moderate because the risk falls between the diagnosis and data complexity.