Wiki MDM hospital consult

[Nvgrant]

Hi, I'm trying to code a hospital consult and I'm struggling with the MDM. The CC is eye discharge. This is the assessment:

A/P
# preseptal cellulitis OS
# bacterial conjunctivitis OU OS > OD
- no signs of orbital cellulitis at this time, would not recommend further imaging
- start Doxy 100mg BID PO and polymycin/bacitracin ointment TID OU
- will follow up in a week for resolution of symptoms and double vision
- continue WC BID for 10 minutes at a time

I know the drug management qualifies as moderate. But I get tripped up with the diagnosis. With eyes, what's considered self-limited or minor? Or acute, uncomplicated? It's hard to find examples for ophthalmology.

 

[Cheezum51]

I've struggled with this as well and been unable to find any definitive "list" of diagnoses which would help back up my thoughts on what constitutes various levels of risk or problem. Therefore, I make my decision on Risk and Problem based upon my 40+ years of practice experience.

In your example, I would classify the conjunctivitis as an acute uncomplicated problem.

However, for the preseptal cellulitis, I would classify that as an undiagnosed new problem with uncertain prognosis. Mainly because I've seen several of those cases not respond well to certain treatments as expected which gives me the "uncertain prognosis" part of this.

Therefore, in this case, I'd use the preseptal cellulitis and prescription drug management to code this as a level 4 E/M visit.

Tom Cheezum, OD, CPC, COPC

 

[Nvgrant]

Thank you Tom! Level 4 is where I finally landed as well after flip flopping back and forth. This is still new to me and I'm trying to build confidence to make a decision and stick with it.