Neurosurgery Coding Alert

Question: If a patient has a bilateral problem (for example, the patient has tingling down both the left and right arms), 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 tingling with a single prescription, then you would regard this as a single problem. However, if the patient had acquired injuries to both arms, or each arm had a different problem, then you could conceivably regard this as two problems.

Warning: Counting this as two problems when tallying MDM will be the exception, not the rule. Proceed with caution when considering this coding route.