Wiki Number of Diagnoses or Treatment Options

[Chelsea1]

I have a patient being seen by Cardiologist for recurrent unexplained chest pain. This is the only thing the patient complains of. When choosing a Dx/Treatment Option on the E&M, I am using the Est. problem (to examiner); worsening. My question is, the Dr. ordered a Cath along with a prescription of Cardizem, can I put a 2 for number of treatment options?
Est. problem (2) X number of treatment options (2)= 4

 

[jdibble]

I have a patient being seen by Cardiologist for recurrent unexplained chest pain. This is the only thing the patient complains of. When choosing a Dx/Treatment Option on the E&M, I am using the Est. problem (to examiner); worsening. My question is, the Dr. ordered a Cath along with a prescription of Cardizem, can I put a 2 for number of treatment options?
Est. problem (2) X number of treatment options (2)= 4

In the above situation, you would assign the 2 points for the Established problem, worsening. That is the only thing you can assign under the Number of Dx/Treatment Options section since that is the only diagnosis being treated. The ordering of the cath and the Rx of Cardizem could be used to establish the risk (under Moderate), but it would have no place in the treatment options section.