EM Coding Alert

Question: If a patient has a bilateral problem (for example, the patient has rheumatoid arthritis of both the left foot and right foot), does that count as one or two problems for the purpose of medical decision making (MDM)?

AAPC Forum Participant

Answer: Counting a bilateral illness or injury as one or two problems in the Number and Complexity of Problems Addressed at the Encounter element of MDM will very much depend on whether your provider is evaluating and treating the conditions separately or as one condition.

In the example you give, if a provider treats the arthritis with a single prescription, then you would regard this as a single problem. However, if the patient had acquired injuries to both feet from an accident, and each foot had a different problem (say, an ankle sprain to the right foot and broken bones in the left), then you could conceivably regard this as two problems.