I have a question about data points for MDM. Below is an example of data documentation I would appreciate any feedback on how may points you would assign. Example is as follows:
BMP is remarkable for a potassium of 3.5 and a glucose of 144. Total
bilirubin is also slightly elevated at 1.4.CBC shows a hemoglobin of
14.6; WBC 9.2; platelet count 193,000; 63 polys, 11 monocytes. PT is 12.
CT of brain without IV contrast, reveals unchanged deep penetrating artery infarct in the anterior left corona radiata. There is no evidence of acute infarct, hemorrhage, mass or mass effect. The EKG, independently reviewed by me, reveals sinus rhythm at 70 with normal axis, QTc prolongation, but no acute ST-T wave changes. There are nonspecific ST-T wave changes. Chest x-ray, also independently reviewed by me, reveals no acute disease with healed rib fracture on the right.
any help appreciated, thanks
BMP is remarkable for a potassium of 3.5 and a glucose of 144. Total
bilirubin is also slightly elevated at 1.4.CBC shows a hemoglobin of
14.6; WBC 9.2; platelet count 193,000; 63 polys, 11 monocytes. PT is 12.
CT of brain without IV contrast, reveals unchanged deep penetrating artery infarct in the anterior left corona radiata. There is no evidence of acute infarct, hemorrhage, mass or mass effect. The EKG, independently reviewed by me, reveals sinus rhythm at 70 with normal axis, QTc prolongation, but no acute ST-T wave changes. There are nonspecific ST-T wave changes. Chest x-ray, also independently reviewed by me, reveals no acute disease with healed rib fracture on the right.
any help appreciated, thanks