Wiki MDM Risk table STD check

[missy874]

Hi, I am looking only at the first column of the Risk table.... Low vs. Moderate. Would you consider (potential) exposure to STD low vs moderate.... I don't think there is a lot of stuff going on besides labs but I am hung up on the verbage "undiagnosed new problem with uncertain prognosis..." would you only consider this if the patient was experiencing symptoms? He is not showing symptoms--just is concerned because of exposure.

Thanks

 

[jwhassjr]

I don't believe you have anything within column one of the table of risk based on the synopsis you present. In the absence of signs or symptoms, I don't believe the patient has a "presenting problem". Therefore I would focus on column two, and if labs were ordered, it would appear that your risk is minimal.

 

[sbicknell]

If the patient came in with no symptoms, potential exposure, then this is an STD lab screening and I would give it a SF Risk

If the patient came in with symptoms, potential exposure, then I would probably give it Low for acute uncomplicated illness (until proved otherwise)

The "undiagnosed new problem with uncertain prognosis..." is more (example) a patient with a cough, office chest xray abnormal with an order for a CT. Basically this is for "I don't know what I am dealing with and don't know where we are headed till we do some more tests"

I just wouldn't give it Mod risk for potential exposure. But it would really depend on the whole note.

 

[missy874]

Thank you. I wanted another opinion as the provider wanted a fairly high visit and I just couldn't see that it was supported. It helps to have more than one opinion when you need to "downcode" a provider