seniar
Guest
My question is in regards to guidelines for determining the correct level of "Medical Decision Making" when coding an officevisit. Specifically determining the score for the "Number of Diagnoses or Treatment Options".
I am coding an officevisit for an established patient presenting to the office for a vaginal infection. Our practice is OB/GYN. The provider documents this is a new problem that has not been treated before. This is the only problem the patient is presenting for today. The physician orders cultures that is resulted while the patient is in the office. When determining the score for "Number of diagnoses or treatment options" part of the MDM score, would it be appropriate to select 3 points for "New problem to examiner, no additional work-op planned" or would it be more appropriate to select "Self-limited, or minor" for just 1 point?
I am coding an officevisit for an established patient presenting to the office for a vaginal infection. Our practice is OB/GYN. The provider documents this is a new problem that has not been treated before. This is the only problem the patient is presenting for today. The physician orders cultures that is resulted while the patient is in the office. When determining the score for "Number of diagnoses or treatment options" part of the MDM score, would it be appropriate to select 3 points for "New problem to examiner, no additional work-op planned" or would it be more appropriate to select "Self-limited, or minor" for just 1 point?