Wiki E&M MDM Level of Risk

[travelrunner@msn.com]

E&M coders, for the MDM Level of Risk, do you focus on the presenting problem as opposed to the final diagnosis?

Example: Say that a patient went to the emergency dept with chest pain. The Dr. does an EKG, Lab (only one Troponin), chest x-ray, and rules out an MI. The final diagnosis is Chest Pain and Anxiety.

#of diagnosis/treatment options is MODERATE
Amount of data reviewed/ordered is HIGH
Level of risk______?

Would you assign a higher level, 5, based on the life-threatening potential of an MI? Or, possibly a level 4 because the patient did not have an MI?

 

[thomas7331]

1995 guidelines state that the "risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment." I would interpret that to mean the risk should be based on the provider's assessment of what the patient's risk is going to be following the encounter, not what the potential risk was when the patient arrived. So I would assign a moderate MDM in your example, based on the criteria you've given above.

 

[travelrunner@msn.com]

Thank you, this is very helpful!