Wiki Parenteral controlled substances

[tetyana]

I am looking for second opinion on this:

If the patient has Opioid addiction or dependence, and he is in rehab facility for Opioid addiction. He has history of using parenteral controlled substances. He is stable now, receiving treatment for dependence. Is the risk - High? MDM - high complexity? (history - comprehensive, exam - comprehensive, MDM -moderate or high? 99222)
Thank you

 

[thomas7331]

Parenteral controlled substance is listed under 'management options' in the table of risk - it's there for when the provider is using these to treat the patient, not when the patient has a history of using them due to drug abuse.

There's not really enough information here to know the MDM level - it looks like 1 chronic stable problem (1 diagnosis point & low risk = SF MDM) from what you've included, but I'd want to see what else the provider is actually evaluating and addressing as far as a treatment plan.

 

[tetyana]

Thank you,
4 diagnoses, new to provider 8 points - extensive, labs reviewed 1 point Limited; (other doctor's record reviewed - 2 points moderate. Patient is not suicidal, no acute distress, no severe exacerbation mentioned, detox medications prescribed - moderate . Provider feels like this is high complexity 99223. I think this is moderate 99222. Two others key components comprehensive 99223. This is a new patient 3 of 3 components are required.
Correct me if I am wrong.