Wiki Mdm

[msingh23]

Need some feedback if this justiy for Moderate MDM for Dr. states order indicate "MRI rule out" his give higer credit per a pervious audit.

CC: Left Groin pain, bilateral ankle pain

Dx:
GROIN PAIN (ICD-789.09)
ANKLE PAIN, BILATERAL (ICD-719.47)

MDM
Pt will get me copy of ultrasound report
Pelvic MRI, Sports Hernia Protocol, r/o sports hernia, osteitis pubis, adductor strain/tear
X-ray B ankles
Consider MRI of the ankles
Thanks

 

[skraft1969]

If these problems are new to this provider then you have 4 points for number of diagnosis or treatment options (New problem (to examiner); add'l workup planned (MRI) and then risk of complication and/or Morbidity or Mortality we have an undiagnosed new problem with uncertain prognosis It would be my opinion that this would meet a Moderate MDM.

 

[msingh23]

E/M Level

Thank you for the detail appreciate

 

[MaryG215]

Add'l Workup

I had a similar question and asked our consulting firm and was told the following:

Recommend MRI implies the provider thinks there should be add'l workup and would count this, HOWEVER, if provider states "May consider MRI" it wouldn't be counted towards add'l workup.