Wiki ENT consult for MDM number of dx and mgt options

Create Wiki Sort by date
W

wynonna

True Blue
Messages
539
Location
Hinsdale, MA
Best answers
0
Patient being treated by ENT consultant and was admitted for Nasal severe epistaxis and COPD.
COPD important because pt is oxygen dependent and has nasal cannula 24/7 at home and while IP.
Pt also has long term use of baby aspirin.
How many points under Number of Diagnoses/Management Options would this be counted as?
(aspirin use can contribute to nasal bleed)
(oxygen tubing is inserted and stays through nose for continuous oxygen support)
Thank you
 
0
For I/P services there are no New or Established patients. So for the initial encounter it's always considered a new problem for that physician. For the two medical conditions you have listed you have four PP which is all you can get. And just a heads up, don't use the word "Consult" unless the visit meets the qualifications for it which would be the three R's rule. If it does not meet the three R's it's not a consult. Just because one doctor wants the patient to be seen by a doctor of a different specialty does not make it a consult.
 
0
Thank you for your help:
I am thinking of Number of diagnoses/management options for a subsequent visit. The first box under MDM. Presenting problems may be signs or symptoms, not necessarily a final DX established by the MD. Not sure if there is a big difference on how they are defined or counted. (signs and symptoms or Presenting problems may very well turn out to be the final dx too)
Thank you
 
0
wynonna said:
Thank you for your help:
I am thinking of Number of diagnoses/management options for a subsequent visit. The first box under MDM. Presenting problems may be signs or symptoms, not necessarily a final DX established by the MD. Not sure if there is a big difference on how they are defined or counted. (signs and symptoms or Presenting problems may very well turn out to be the final dx too)
Thank you
Click to expand...
OK, so if your coding a subsequent visit, it would be just like an established patient. If the epistaxis is improving or responding to treatment then that would be one PP. The COPD would be another. That would be two. Signs or symptoms of a known diagnosis that is already being treated is not counted.
 
0
I understand your point, and thank you for your insight. My thought is this:
(aspirin use can contribute to nasal bleed)
(oxygen tubing is inserted and stays through nose for continuous oxygen support)
So even though these are not illnesses, but are contributing factors influencing the care plan, can they also be counted for this subsequent visit? (For a total of 4 points) dx: epistaxis, COPD, oxygen dependence, and long term aspirin use
thank you so much
 
0
Good Morning, I am going to question the possibility Z79.82 can be counted as a diagnosis/management option but nobody has mentioned why this individual is on long term use of aspirin (condition?) and how it was managed during his hospitalization and post-discharge. Certainly with epistaxis there had to be some sort of management of their aspirin, was it d/c'd or dosage changed? was the patient given something to counter act the effects of the aspirin? These are things to consider as you do not want to short change your provider and the amount of work they are actually doing. This all comes back to the provider and making sure they document all their work appropriately to receive credit for everything they do.

These were just my thoughts while reading thru the responses.
 
You must log in or register to reply here.
Top