Wiki Medical Decision Making

[CrazyCodingMom]

I am working on E/M Visits with URI symptoms and as I am going through the report the exam seems general to the problem but the doctor gives medications and as I am filling out an audit form it takes the visit from a low complexity to a moderate complexity. Is this correct since the visit is just basic for URI symptoms but the doctor gives medication? Should it be a low complexity visit instead?

 

[a.renee86]

When determining MDM you take the 3 sections into consideration, Problem points (how many and the severity of the diagnoses), Complexity of data reviewed (if provider ordered/reviewed labs, radiology, etc.) and the Risk, which with the prescribing of medication would be Moderate. You take two out of three of those components to determine the MDM. You could have a moderate MDM for a simple URI, it depends on what was done for the patient.


Hope this helps!
Amber
NCICS, CPC, CPMA