Wiki Number of Management Options

[wynonna]

A provider documents 3 diagnoses under Assessment.
Her exams are always level 4 with at least 6 body/organ systems for detailed level 4 exam. History sections vary.
Would visits with level 4 detailed exams and 3 diagnoses under Amount/complexity of data be all level 4? with key factor being at least 3 dx listed in assessment? Assuming table of risk is moderate/level 4 (Prescription drug Management) also assuming 1 or less points under Amount and complexity of data (low or minimal)
thanks

 

[thomas7331]

Management of 3 or more problems or chronic conditions involving prescription drugs generally would qualify as moderate MDM. So for an established patient visit with a detailed exam, yes, these would qualify as level 4 visits. I would add though that, in my experience, many auditors look for more than just having 3 diagnosis codes listed. The documentation should also reflect that all three problems were assessed and treated or influenced treatment decision at that encounter in order to warrant being counted toward the complexity of the MDM, and that the level of history and exam are appropriate to the presenting problems.

 

[wynonna]

THANK YOU! Very helpful