Wiki Medical Decision Making/overall risk

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jaldrich

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Ok...I'm new enough to coding that I find myself having a panic attack when I have to evaluate Medical Decision Making documentation. I have an example and I'd love input from anyone who can tell me what level of MDM you would give this: (it's only the A/P part of the note, but based on what you see here, how would you code?) I removed any true patient identifying information

ASSESSMENT AND PLAN:

1. A 51-year-old gentleman with significant snoring, morbid obesity and frequent awakening at night. The neck circumference is more than 17 inches. Suspect significant underlying sleep apnea. I counseled patient for exercise, weight reduction, calorie restriction and offered him polysomnograph overnight sleep study for which he agreed and scheduled, which will be discussed with him on followup visit. If positive for sleep apnea he will have a mask for positive pressure.


2. Active severe smoker and recovered alcoholic, but still moderate use of alcohol. Patient was counseled for complete smoking cessation, especially in the presence of his risk factors. He was also recommended to stay off of alcohol completely and quit smoking completely.

3. Intermittent bright red minor rectal bleeding. Etiology unclear, but positives stools for occult blood. I offered him a colonoscopy especially when he is 51 too. Never had any colon test before. Agreed and scheduled with Dr. X for colonoscopy.

4. Hypertension, controlled. I recommend to continue with Lisinopril, which is good for renal protection too and encouraged to exercise, low salt diet and weight reduction.

5. Minor depression. I did offer him antidepressants but he declined that. He stated that it was more so during holiday season and it is better now.

6. Type II diabetes mellitus with early diabetic neuropathy without any ulcers, and morbid obesity, status unknown. Consult for 1600 ADA diet. Encouraged one-hour exercise. I recommended to lose weight gradually. For now I kept him on Metformin and Glipizide and I have ordered a CBC, comprehensive metabolic panel, lipid panel, PSA, TSH, microalbumin, hemoglobin A1C and 12-lead EKG. He will be reassessed in my office in the next three to four weeks and adjust his medications accordingly. He already has undergone diabetic education and following the diet at home, but his risk factor he definitely needs to quit smoking and alcohol completely. His diabetic neuropathy is going to be watched at this point of time. He does not need any medication or does not have any pain.

7. BPH with frequency. PSA ordered. On followup visit if his PSA is normal and he is still having this frequency of urination, which I believe is multifactorial, including his obesity, diabetes, and lack of physical activity, then we will consider adding him on alpha-blockers.

8. Degenerative osteoarthritis with obesity consult for exercise, weight reduction and p.r.n. use of Tylenol or Advil.

9. Tetanus diphtheria was administered today. He requested all of his prescriptions be refilled and that was done for six months. He is scheduled for a colonoscopy and overnight sleep study. Further followup and assessment in two to three weeks. Patient agreed. Arrangements were made. Stable, and having good understanding of the discussion done in my office today, taking close to 60 minutes of patient care time in my office.

Thanks for help in advance!
 
It appears that you have an extensive number of diagnoses/treatment options; moderate risk; and multiple amount/complexity of data. MDM appears to be moderate/level 4 - to me. Too bad documentation of time is not better, to support high complexity MDM.
Lisa
 
jaldrich said:
Ok...I'm new enough to coding that I find myself having a panic attack when I have to evaluate Medical Decision Making documentation. I have an example and I'd love input from anyone who can tell me what level of MDM you would give this: (it's only the A/P part of the note, but based on what you see here, how would you code?) I removed any true patient identifying information

ASSESSMENT AND PLAN:

1. A 51-year-old gentleman with significant snoring, morbid obesity and frequent awakening at night. The neck circumference is more than 17 inches. Suspect significant underlying sleep apnea. I counseled patient for exercise, weight reduction, calorie restriction and offered him polysomnograph overnight sleep study for which he agreed and scheduled, which will be discussed with him on followup visit. If positive for sleep apnea he will have a mask for positive pressure.


2. Active severe smoker and recovered alcoholic, but still moderate use of alcohol. Patient was counseled for complete smoking cessation, especially in the presence of his risk factors. He was also recommended to stay off of alcohol completely and quit smoking completely.

3. Intermittent bright red minor rectal bleeding. Etiology unclear, but positives stools for occult blood. I offered him a colonoscopy especially when he is 51 too. Never had any colon test before. Agreed and scheduled with Dr. X for colonoscopy.

4. Hypertension, controlled. I recommend to continue with Lisinopril, which is good for renal protection too and encouraged to exercise, low salt diet and weight reduction.

5. Minor depression. I did offer him antidepressants but he declined that. He stated that it was more so during holiday season and it is better now.

6. Type II diabetes mellitus with early diabetic neuropathy without any ulcers, and morbid obesity, status unknown. Consult for 1600 ADA diet. Encouraged one-hour exercise. I recommended to lose weight gradually. For now I kept him on Metformin and Glipizide and I have ordered a CBC, comprehensive metabolic panel, lipid panel, PSA, TSH, microalbumin, hemoglobin A1C and 12-lead EKG. He will be reassessed in my office in the next three to four weeks and adjust his medications accordingly. He already has undergone diabetic education and following the diet at home, but his risk factor he definitely needs to quit smoking and alcohol completely. His diabetic neuropathy is going to be watched at this point of time. He does not need any medication or does not have any pain.

7. BPH with frequency. PSA ordered. On followup visit if his PSA is normal and he is still having this frequency of urination, which I believe is multifactorial, including his obesity, diabetes, and lack of physical activity, then we will consider adding him on alpha-blockers.

8. Degenerative osteoarthritis with obesity consult for exercise, weight reduction and p.r.n. use of Tylenol or Advil.

9. Tetanus diphtheria was administered today. He requested all of his prescriptions be refilled and that was done for six months. He is scheduled for a colonoscopy and overnight sleep study. Further followup and assessment in two to three weeks. Patient agreed. Arrangements were made. Stable, and having good understanding of the discussion done in my office today, taking close to 60 minutes of patient care time in my office.

Thanks for help in advance!
Click to expand...



After reviewing the above, I give it a Moderate MDM... if the physician would have documented the time of counseling it would be a differant story.

I'd educate the physician on documenting the counseling.

Regards,

Roxanne Thames, CPC
 
Level 5

I would definitely code this a level 5. This patient is not getting enough O2 at night and not enough sleep which on a cumulative basis puts him at high risk for morbitity. Also, it is possible that he is exibiting symptoms of rectal or colon cancer with the rectal bleeding. Sounds like the physician spent 60 total minutes with this patient. Although he does not say that > 50% of the time was spent counseling the patient he could still document it if this was the case which would definitely support the level 5. Even without the time documentation I would feel confident that I/we could support a high level of service.

Good Luck to you. You are not alone.
 
I disagree, I would say a Level 4 because you state that the patient is "Stable" in your A&P. Billing based on time is for when counseling/coordination care becomes the key or controlling factor. When > 50% of the total time is spent counseling you can select your E/M code based on total time. Your documentation must support counseling.

Counseling is a discussion with the patient concerning one or more of the following areas:

Diagnostic results, impressions
Prognosis
risks and benefits of treatment options
instructions for management and/or follow up
importance of compliance
risk reductions
patient and/or family education


Billing based on time should be used as a exception not the rule.
 
Obviously this patient has multiple conditions/presenting problems, so we've already met our max on the problem points 4+

now it's a battle in the Table of Risk

.....and I'm suprised no one mentioned "endoscopy with risk factors"

afterall, a colonoscopy is a minimally invasive endoscopic examination.

you have High Risk and High Medical Decision Making
 
Moderate Risk, but ...

I get moderate risk.
I see your point, AR, re the endoscopy w/ risk factors, but I'd still consider a colonoscopy as a "minor surgery w/ identified risk factors." I checked with two PAs in our general surgery office and they both would consider the colonoscopy as minor.

BUT ... we have 4 points for Dx (new probl w/ workup - rectal bleeding)

And we possibly have 4 points for Data: 1 for ordering labs; 1 for ordering sleep study; and possibly 2 for discussion w/ another healthcare provider (it's hard to tell from this whether all the consults involved his actually speaking w/ the nutritionist, diabetic teaching professional, GI doc, or sleep lab physician) -or- 2 pts for independent visualization of specimen if he took and studied the occult stool sample himself.

IF you can get 4 data points, you have High Complexity of MDM (You only need 2 of the 3 parts of MDM to equal the level)

As for the time ... I couldn't tell if this was a new patient or an existing patient. But from the description provided, it does seem that much of the visit was spent in counseling. The physician's notes speak to talking to the patient about smoking cessation (several times), stopping alcohol (several times), offering options re his recurring holiday depression, weight loss, exercise, DM management, reasons for colonoscopy, offering a sleep study, etc. He even states that the sleep study and colonoscopy are scheduled for the patient (coordination of care). The only thing the doctor didn't say was that greater than 50% of the 60 minutes was spent in counselling/ coordination of care. If he's amenable to doing an addendum, that would cover the coding based on time. ..

Here's another option for you ... Prolonged service.

IF the patient is established, and the rest of this note only supports a 99213 visit. The usual time frame for this is 15 minutes; your doctor spent 60 minutes, so 45 minutes of prolonged service is documented (in addition to all the bullet points for 99213) and you can code that as
+99354.

F Tessa Bartels, CPC, CPC-E/M
 
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moderate....I work w/ general sx who perform colonoscopies every day and they are not considered high risk. The rectal bleeding is most likely contributed to hemorrhoids.
One thing is for sure, this doc documents good. I wish my did as well.
 
abenson said:
moderate....I work w/ general sx who perform colonoscopies every day and they are not considered high risk. The rectal bleeding is most likely contributed to hemorrhoids.
One thing is for sure, this doc documents good. I wish my did as well.
Click to expand...

as far as documentation is concerned mdm requires number of dx that need to be specified if new or estab dx/amount of data/and the risk. Im not sure if the question is with regards to the risk, ...if its for the risk then i would say moderate: 4 chronic conditions that seems to be stable...and few self limiting conditions.
 
If you get the physician to add time to the smoking cessation counseling in the future. You can bill also

99406- Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 min.

99407- intensive, greater than 10 min.

Just some added input.

Daniel, CPC
 
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