Wiki MDM level with no treatment plan or action documented

[MnTwins29]

Fellow E/M coders - what would you do here? Patient has two estabilshed problems well controlled. Physician lists these in assessment area of progress note, but has no treatment plan documented - not even "continue" anything like meds, regiment, etc.

Where my discomfort comes is in using the E/M audit tool, for the MDM portion, there would be 2 points for two established problems, stable or improved, and the risk level is moderate because there are two or more stable chronic illnesses. So, that results in a low level of MDM with NO treatment actions documented. Is this allowed?

 

[Willingham]

MDM w/no A/P

I would definitely use the E&M audit tool this would be your guide as to how the level was obtained and if the provider did not indicate any plan or tx. then it sounds like the MDM would be straightforward because the dx. are stable. Did he review any labs? Remember for an established pt. you need 2 out of three for a level and if you reallly feel uneasy then query the provider. But also remember the documentation is what it is, and maybe if you do query the provider I would send an email to let them know for future references (educational) the DG for the 3 key components of an OV.

Hope this helps......

 

[abhishekrane32@yahoo.com]

If two established problems are documented first check whether they are stable or worsening. if stable it will count 2 points only in no .of Dx section. I will give Moderate Risk for two stable established problems which counts 3 points in risk section. if nothing is there for number of data points. Overall MDM will become LOW.I hope it will help.

Abhishek Rane CPC