Wiki Moderate or high MDM?

[wynonna]

Patient has Hemoptysis, pneumonia, confusion, tongue cancer with radiation 2 days ago.
ENT evaluated need for surgical intubation this morning. Upon exam the patient is stable and able to maintain his own airway. Tongue is bloody and looks blown out. Would this be High MDM under Number and complexity of problem addressed? (1 chronic illness--tongue cancer with severe exacerbation or progression or side effects of treatment--radiation.) Patient is going to be admitted but so far I'm looking for 2021 MDM guidelines to figure out if this is moderate or high level decision-making?
Would this be High Risk for sending patient to the hospital? (Decision for hospitalization)

 

[lindseykelly3191]

HIGH.

 

[wynonna]

Decision for hospitalization not made by us, but another facility did. We did not do the physical transfer via ambulance.

 

[wynonna]

It does look high to me too on first glance. But we are not oncologists-we are ENT. Another facility did the recommendation for and transfer to other facility. Pt in observation status and being transferred to get care at hospital with more resources.
Pt is stable and able to maintain his own airway upon exam.
Do you still see as High Risk for complexity of problems and risk of complications?

 

[trarut]

I would consider this MDM to be high risk. The patient still has tongue cancer with severe side effects of treatment and I presume your physician is making decisions related to care and treatment going forward in addition to the fact that the patient is at increased risk of dying as a result of these side effects (Diagnosis & Risk).