TTcpc
Guru
Hello,
I am working with a pediatric specialty group and would like some opinions regarding how to "grade" this risk for the MDM. The patients are in the GI clinic as new patients often with reflux, projectile vomiting, and fussiness after feeding as the primary complaints from the parents. The providers aren't doing any additional work-up, not ordering any labs/rad, and usually just adjusting formula, having the mother change her diet if breastfeeding sometimes will have them start Zantac for possible GERD. So I'm getting new patient/no additional work-up = moderate; no labs/rad/records reviewed = straightforward. The risk is were I'm getting myself confused..no Rx, feeding recommendations so I'm hitting low risk OR if I consider it a chronic problem (most have had it since birth or at least a month or more without improvement) with mild exacerbation I would have moderate risk OR is the infant too young for it to really be considered a "chronic" condition and I consider it acute uncomplicated illness???
I have a feeling I'm overthinking this, but it could honestly make the different in the CPT level between the Low and Moderate MDM.
Thank you!
I am working with a pediatric specialty group and would like some opinions regarding how to "grade" this risk for the MDM. The patients are in the GI clinic as new patients often with reflux, projectile vomiting, and fussiness after feeding as the primary complaints from the parents. The providers aren't doing any additional work-up, not ordering any labs/rad, and usually just adjusting formula, having the mother change her diet if breastfeeding sometimes will have them start Zantac for possible GERD. So I'm getting new patient/no additional work-up = moderate; no labs/rad/records reviewed = straightforward. The risk is were I'm getting myself confused..no Rx, feeding recommendations so I'm hitting low risk OR if I consider it a chronic problem (most have had it since birth or at least a month or more without improvement) with mild exacerbation I would have moderate risk OR is the infant too young for it to really be considered a "chronic" condition and I consider it acute uncomplicated illness???
I have a feeling I'm overthinking this, but it could honestly make the different in the CPT level between the Low and Moderate MDM.
Thank you!