Wiki MDM Diagnoses and management options

[dwaldman]

Medical record indicates the patient will have pain medications refiled. They have lumbar radiculopathy that the physician indicates is bothersome. Plan indicates the patient will follow up to clinic for lumbar epidural with fluoroscopy.

Can you count 2 management options with 1 Dx as: prescription medication and epidural, to add up to 3 points for Diagnoses/management options and then state moderate risk for the prescription drug management for moderate medical decision making. The examples that I have seen on E/M university, Dr Jensen is counting established problems based on if they are stable or worsening/not responded to treatment. But it does not appear he is mixing management options and diagnoses in counting the number of diagnoses when there is no data reviewed/ordered but there is prescription drug management.

This would be for an established patient with detailed exam 97 and extended HPI thru an EHR. But throwing out the HPI because it appears almost identical to the prior visit other than the pain score.

 

[dwaldman]

I was hoping to get some responses but that is ok. Here is a response I got from a different forum

you are using the point system for determining the MDM you are looking at the Diagnoses; Test/Review; Table of risk

You have a diagnosis of Lumbar radiculopathy that is 'bothersome' that appears to be a chronic condition of the patient correct? This appears to fall under established failing to change - which would be 2 points which is LOW

For the amount and/or complexity of Data to be reviewed - what do you have?

For the Risk portion - they are talking about Rx as well as epidural so that would be a moderate -- for the risk you take the overall highest in the table and epidural and meds both fall under Moderate, I don't get two separate points.

This would be an overall LOW since you have Low/none/Mod - unless there is Data I am not seeing

Here are some URLs that have some tools for counting points and other issues:
http://www.aaos.org/news/bulletin/may07/davidson_tables.pdf

http://medicare.fcso.com/include/em_license.asp
http://medicare.fcso.com/EM/165590.asp
Number of Diagnoses or Management Options

The number of possible diagnoses and/or the number of management options that must be considered is based upon the number and types of problems addressed during the patient visit, the complexity associated with establishing a diagnosis, and the management decisions that are made by the physician.

Instructions: For each of the qualifying elements listed below, please enter the number of occurrences that match the criteria specified within the element. For additional guidance, please refer to either the 1995 or 1997 E/M documentation guidelines.


Presenting Problem

Self-limited or minor problem(s) -- stable, improving, progressing as expected, or resolved

Established diagnosis or diagnoses -- stable, improving, or resolved

Established diagnosis or diagnoses -- inadequately-controlled, worsening, or failing to change as expected

New problem to examiner -- no diagnostic procedures ordered

 

[cpclori]

Thanks for sharing this information. These are very helpful tips!