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ladonna2192

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I would appreciate an opinion on the level of MDM for the following:

ASSESSMENT and PLAN
1. Anemia: Probably from chronic blood loss form the 10mm duodenal bulb ulcer and gastric erosions which were thought to be secondary to ASA. There was no clinical evidence of active bleeding but she did drop her Hgb. I would suggest testing all stools for heme. If positive would connsider repeating the EGD, performing a colonoscopy, or a PillCam. I would suggest finding out whether she really needs chronic ASA therapy and if not stop it. If she does need it, it should be decreased to 81mg daily and continue PPI BID for a total of 1 week and then decrease to daily while she continues on ASA. She is tolerating a diet without difficulty.
 
It's really hard to tell, with what you've shared. MDM isn't abstracted just from the Assesment/Plan. We need to see the entire note, to determine the nature of the presenting problem. Is this a new problem? Was there additional workup done? What other issues does the patient have? Were records reviewed? That's not clear in just the documentation that you've provided.

Try not to get caught up in just looking at Assessment/plan to determine MDM. You have to look at the whole picture in order to come up with the appropriate level of service. Just as you can sometimes find HPI elements in the exam, you often find information to deterimine MDM in other areas of the note.
 
Here is the entire note:

SYMPTOMS: The patient is looking and feeling well. Her Hgb dropped this morning and she feels much better after a blood transfusion. No BRBPR or malena and no abdominal pain.

PHYSICAL EXAM:
Vital Signs:
Temp Pulse Resp BP Pulse Ox
98.3 F 86 20 166/54 H 91
05/27/13 20:45 05/27/13 20:45 05/27/13 20:45 05/27/13 20:45 05/27/13 20:45

General: Fully oriented and comfortable.
Chest: Good air movement and clear with no added sounds.
Heart: No murmurs.
Abdomen: Soft, non-tender, not distended, no masses, no organomegaly, no hernia.
Extremities: No ankle edema, no joint swelling.

INVESTIGATIONS:

05/27/13 05/27/13
05:34 07:54
RBC 2.60 L
Hgb 7.9 L*
Hct 24.4 L
RDW 16.1 H
Potassium 5.5 H
Chloride 113 H
Carbon Dioxide 19 L
BUN 59 H
Creatinine 2.1 H
Crossmatch See Detail

ASSESSMENT and PLAN
1. Anemia: Probably from chronic blood loss form teh 10mm duodenal bulb ulcer and gastric erosions which were thought to be secondary to ASA. There was no clinical evidence of active bleeding but she did drop her Hgb. I would suggest testing all stools for heme. If positive would connsider repeating the EGD, performing a colonoscopy, or a PillCam. I would suggest finding out whether she really needs chronic ASA therapy and if not stop it. If she does need it, it should be decreased to 81mg daily and continue PPI BID for a total of 1 week and then decrease to daily while she continues on ASA. She is tolerating a diet without difficulty.
 
Interval HPI is clearly EPF. Since he documented no BRBPR, I'd probably give a detailed GI exam (masses, organomegaly, hernia, rectum). From an MDM perspective:
I'm assuming this is an established problem, improved. Don't assume multiple diags = multiple problems. This is all one big clinical picture..anemia due to either GI bleed or ASA use. Labs ordered/reviewed, but he is going to ask (someone?) about the need for ASA Therapy. It's kind of a stretch, but I might give a data point for that to give you limited data, since this is a bit of a tricky picture. The patient's electrolytes are off...but he didn't mention the implications of that. He is considering intervention--GI scope, depending on the results of the guaiac. The question is whether or not the bleed constitutes an endoscopy risk. I'd say no (moderate risk), but even if it was a high risk procedure with a positive guaiac, your presenting problem and data wouldn't bump you any higher for MDM. He's questioning etiology, and questioning ASA continuation, but that's an OTC drug..... Sometimes those unknowns can provide a higher risk, but he's already suggesting an EGD, so you wouldn't gain anything there.
So, I think it would be a stretch to suggest this is more than a low MDM. (Established problem stable, Limited Data, and Moderate Risk) I'd query the provider...."Is the anemia due to GI bleed, to long term ASA use, another reason, or not known?" That way you're not reporting Anemia NOS in an inpatient setting. This could have been so much more...but documentation wasn't there. I suggest to the providers that they tell me what they're thinking..."what's in your head?" Good luck.
 
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