Wiki Mdm risk

[missy874]

Good morning, I would like an opinion of the risk level of this mdm (not concerned with data points, or problem points). Provider feels this is high risk. Please let me know what you think and rationale if possible.
Thanks in advance:

Assessment and Plan: The patient is being seen for the following problems:

#Upper GI bleed in the setting of etoh liver cirrhosis/severe esophagitis. GI recommended for conservative management.

#Chronic anemia - H/H stable.

#Abdominal ascites/Abdominal pain. CT abdomen/pelvis with findings of liver cirrhosis/varices; moderate ascites.

#Hypokalemia - on replacement protocol

#Chronic thrombocytopenia

#H/O breast/bladder cancer - in remission

Plan/Disposition:

Cont PPI/Octreotide gtt

Follow up peritoneal fluid analysis after paracentesis

Start Rocephin for SBP prophylaxis

D/C dilaudid

Trial of prn tramadol

Start Clear liquid diet and ADAT

Check abdominal duplex us

Restart lasix/aldactone tomorrow

Replace sK

 

[LLovett]

Moderate

Clearly this is a very sick patient but there is nothing that I see pushing it to high.

Normally a GI bleed would be high but this is a chronic issue being managed conservatively so no immediate threat to the patient.

I just see a lot of very serious conditions that are controlled.

Just my take on it,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC

 

[emcee101]

Per the table of risk, there is nothing pushing this into the high risk section. It is a very solid moderate risk. all chronic conditions are non-life threatning and stable, and there is no diagnostic procedures or management options listed that would be high risk.

 

[em2177]

Unless the patient is being sent to emergency surgery for the GI bleed then it would be considered high risk. Otherwise, this is considered Moderate risk.

 

[missy874]

Thanks so much! My coders found it to be moderate, but wanted to be sure we werent being conservative in light of the pushback from the provider