Wiki MDM 2021

[KoBee]

Is it a true statement to say, that a patient can have multiple problems but one is really being treated to meet the key elements. You go by what is being treated ? or as long as you just meet any of key elements regardless what is being treated? I hope I’m explaining myself. I think that’s where a lot of confusion is coming from with providers, I want to be able to explain this correctly.



Diagnosis:
Acute uncomplicated injury (hand pain) - low

Acute uncomplicated injury (back pain) - low

Acute complicated injury (head injury) - moderate



Data
X-ray - hand - straightforward


Risk
Norco for back pain - prescription meds for back = moderate


They aren’t really treating all dx. Only dx that got treated was hand with xray and back with meds. Regardless if they don’t treat the head injury and it meets a moderated, can I use the prescription meds for back to meet the guidelines for 99204/99214 under moderate? Or No, since back does not meet a moderate under problems addressed?

Is this a 99204/14 or stick with 99203/13

 

[lindseykelly3191]

you only need 2 of 3 categories for MDM. You could get away with it being an undiagnosed new problem with uncertain prognosis. It's also not just being treated that makes a difference, in addition to that it's what other problems have been "assessed"for example if it says "Follow up with PCP" this doesn't count as being assessed but if it says "Follow up with pcp, and refer to ortho and send for xray" that means it was assessed. Unless they mention the Hand pain being a chronic thing that's stable, you could actually select 1 undiagnosed problem with uncertain prognosis"