Wiki Consideration of MDM

[mdameer159@gmail.com]

Hi, I have a concern regarding consideration of # of Dx's. Any help/assistance on this would be grateful:

When a patient visits a physician for follow-up with below problems:

CC:- 1. Knee pain
2. left Shoulder pain
3. Right Hip pain
4. Low back pain
5. Chronic pain syndrome

Neither of the problem is documented as worsening. Now, in plan, physician is managing the problems in general like, prescription of Norco is documented. Here, I have couple of questions

1. Since it is an established problem(Stable), do we consider only 2 diagnosis or can we consider all the 5?
2. However, the physician is managing all the problems, can we consider this prescription for all the problems?
3. What if the physician is managing only knee pain, LBP and Rt hip pain by prescribing Norco?

And what would be the scenario if the patient is consulting the physician for the first time(New patient).

Thanks & Regards
MA

 

[Pathos]

Welcome to the Medical Decision Making - the most subjective part of E/M. In order to distill Medical Necessity (which is the overarching criterion per Medicare), AAPC suggests using the Marshfield Clinic Audit Tool. For the MDM portion, they have listed out several methods to quantify each section.
Note that you should only ever count diagnoses the provider actively is managing. If the diagnosis listed is not treated or dealt with by the provider, then it would be inappropriate to bill it out.

With that in mind, we always depend on how the documentation is worded. Is the provider piecing out each diagnosis and handling them separately, or bunching them all up with a drug treatment. Without seeing that part of the MDM, I cannot help you much further.