Wiki How to factor additional diagnosis into MDM

[LuckyLily]

How would you factor in additional diagnosis for the MDM that are given in the assessment/plan, when these are not documented in the HPI/Exam of why the patient is coming in? For example, an elderly patient is coming in for knee joint pain and then in the assessment/plan the provider lists Hypertension(refilled meds), Gastroenteritis(wants labs done), Glaucoma(referral given), Diabetes(checks A1C) in addition to the joint pain.

My understanding is that you would not use any of these additional diagnosis to level the MDM, even though for each dx the provider wants more work up done.

I'm looking for feedback on what others are doing when a provider adds additional diagnosis and how the MDM is determined.

 

[thomas7331]

All conditions that are treated, or affect treatment, should be considered toward the MDM - I have never heard of a rule that these have to be included in the history or exam or reason for visit in order to be counted. Part of the reason providers perform a history and exam in the first place is to identify potential comorbidities that have to be taken into consideration in developing a treatment plan. For example, a patient presenting to a general surgeon for a hernia may have a co-existing condition or a history that makes general anesthesia more risky which will make the provider recommend an open repair rather than laparascopic due to the type of anesthesia and/or pain management involved. So of course, these co-existing conditions can complicate the MDM of the visit - the work of deciding on treatment two patients for the same presenting problem may vary greatly depending on these other diagnoses. Patients with multiple problems are by their very nature more complex and involve higher levels of MDM than otherwise healthy patients, even if the presenting problem is the same. So I would include these diagnoses in MDM if the documentation shows that the provider either considered or managed the problems in the course of the visit.