Urology Coding Alert
Know the Basics of Medical Decision-Making
Question: When reviewing data for the third key component, medical decision-making, should I count each blood study my doctor ordered as one unit and can I count each particular tracing that my doctor read as a separate unit? Also, is an ordered urine culture and sensitivity considered a "further workup" in deciding the "diagnostic" level of care?
Rhode Island Subscriber
Answer: In calculating the data portion of the medical decision-making (MDM), you should count each of the various studies that you do in one category only once. Laboratory studies such as a urinalysis, creatinine, and electrolytes that your physician orders count only as one point for laboratory studies.
Also, simultaneously reviewing a urodynamic tracing, CT scan or an IVP counts as only two points for "personal interpretation" of a study, tracing or radiological films.
If the patient needs further evaluation for the urologist to determine the correct diagnosis, such as a urine culture for a suspected urinary tract infection (599.0, Urinary tract infection, site not specified), you can consider this "further workup" when determining a diagnostic level.
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