I appreciate the reply and completely understand about the documentation. I think the key question is medical decision making. With the EMRs today the 99213's would be abundant if I only used the exam and the HPI but I feel the MDM must be a key component. I was leaning towards a 99212 during an audit when I was told a color check is always a 99213. Of course really the doctor should determine the MDM. I'm rambling
Raechel
"Always" is a strong word when you're dealing with things on a case by case basis. An unremarkable color check wouldn't require much (if any) MDM. Abnormal outcomes should be judged by the severity of the condition, and the resulting course of actions that are taken. If the prognosis is good, and there are no risks with the diagnostic and/or treatment processes, the MDM is minimal to low. Both of those CMS guideline links have a "Table of Risk" towards the end, which really helps to categorize the MDM from each encounter, the way that an auditor would. There's also a tool to assess the amount and complexity of data to be reviewed, and one to assess the number of possible diagnosis/management options, which both contribute to the overall MDM. I can't remember if there are instructions, or just the tables, so just in case...
On the table of risk, the highest level applicable to the visit in any of the 3 columns is the overall level of risk.
The other 2 charts are kind of self-explanatory. The # of Dx/Tx options and amount/complexity of data will correspond with ratings from minimal to high. You take the ratings from those categories and the overall risk, and the highest level achieved in 2 out of the 3 categories equals the MDM for most situations.
So, for example:
If there is no data being reviewed, that category = minimal
If the # of Diagnosis/Treatment options category = low, and
If the overall risk from the table of risk = Moderate
Then the MDM will likely be low for the encounter. It's not a perfect system, though, because some of the variables can produce artificially high results, so you still have to use your judgement.
I know I did a horrible job of explaining all of that just now, so if you decide to use that method to determine MDM and have any questions about it, let me know and I'll go more into depth...
(And you thought YOU were rambling...ha!)
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