Wiki E and M for Occupational Health

[cpclori]

Is there anyone doing occupational health coding? Having difficulty with a provider wanting to get moderate MDM every time he writes a script on established patient with follow up on an injury. It is very difficult to get to this because of the dx points and there are rarely any data points. He will add diagnosis like sprain knee, knee swelling, knee pain to try and build dx points. We have had a great amount of back and forth discussion regarding the data points for the problem. He feels these points should be assigned to each diagnosis he lists. If it all the same problem and he is only treating that problem I don't agree. I also have stated coding to highest level of specificity, therefore ankle pain is a sign/ symptom when you have determined it is an ankle sprain. Any other input?
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[rhotonscott]

if he writes a script for pain then the established problem is worsening/unstable and he can claim 2 pts for Dx along with mod risk for meds and get to a level 3. That ASSUMES there is a medical necessity of the script (ie the documentation supports the patient is actually in pain, having problems coping with the injury which necessitated the script)

 

[wrightju1]

You are right about the symptoms vs. dx. If it is an established dx for knee pain the only question is if it is stable/improved or worsening. The most he can score there is 2pts. So, 2 pts for problem addressed, 0 pts for data reviewed, and Moderate MDM for the rx management leaves a Low Complexity MDM. He's not going to get Moderate dealing with one established problem.

 

[MnTwins29]

I would also be concerned about adding diagnoses that are signs/symptoms of a more definitive problem. Adding "swelling of knee" as an additional diagnosis to "sprain of knee" - the swelling would be a symptom of the sprain.