Wiki Flat feet MDM

[andersee]

There are 5 of us that have coded the following 2 scenarios and we can't agree on the level of MDM. Please help!!!!

Scenario #1: A child has flat feet for which the note states she has no pain and no difficulties with any activity. The MD states this problem should resolve itself in 2-3 years and, if she develops pain, she may come back for orthotics. follow-up prn.

Scenario #2: Same as above except the patient also is knock-kneed. No pain, no difficulties. Same A&P.

What is the level of medical decision making in each case (SF, low, mod)?

Thanks much!!!

 

[FTessaBartels]

Self-limited problem

Scenario #1: A child has flat feet for which the note states she has no pain and no difficulties with any activity. The MD states this problem should resolve itself in 2-3 years and, if she develops pain, she may come back for orthotics. follow-up prn.
Self limited problem 1 point / NO data pts / Minimal risk = SF MDM

Scenario #2: Same as above except the patient also is knock-kneed. No pain, no difficulties. Same A&P.Self limited problem x 2 = 2 points / NO data pts / Low risk = LOW MDM

F Tessa Bartels, CPC, CEMC