Wiki MDM help

[blondie12]

If a patient has a rash that ends up as an insect bite. There is a detailed history and exam and doctor prescibes the medrol pack..What level would you code?

 

[Saedron]

New to this so experienced coders feel free to critique!

As far as MDM goes (which is the title of your post):

Risk - Moderate (because of the script management)
Data - zero points (no labs, etc mentioned)
Problem - 1 (self-limited or minor)

Because 2/3 are needed for MDM, your MDM is straightforward.

If you have a detailed history and a detailed exam and straightforward MDM on an established patient, your code is 99214 because you only need 2/3. You have detailed x2. That puts you there regardless of MDM.

For a new patient you'd have a 99202 because you need to hit all three. Detailed history and exam and SF MDM put you at an 02 tops because the MDM never hits Low as far as I can assume without looking at the documentation myself.

Again, anyone feel free to rebut - because I'm newly minted!!

 

[mystarial]

this sounds like a new problem to the provider. They are not doing any workup outside of this visit....so thats 3 points for new problem, no workup planned, 0 for data, and moderate risk for RX. so the MDM would be moderate complexity.

 

[Saedron]

Mystarial -

Forgive my questioning, I am new and trying to learn.

I am not convinced the problem points are 3. A rash or insect bite (both) qualify as self-limited or minor which is 1 point.

So my question is, even though the rash/insect bite is a new problem (acute) does that trump the fact that a rash/insect bite is self-limiting or minor? Because most rashes and insect bites are new problems by nature.

To me a 'new problem, no workup required' is usually used on conditions or diseases, i.e. HTN, DM, Afib, when the patient presents as new to the physician yet has had the condition or disease for years and under control.

Thanks!