Mdm- number of dx's or treatment options

[Vanessa123]

Another coder and I from my office have been asked to do an internal audit on a couple physicians in our practice. We are both unfamiliar with the auditing process and have many unanswered questions. We are looking for any kind of help we can get. We have the the 1997 guidelines auditing tool and we have watched the E/M video on E/M university. These are all helpful sites but we still get stumped when we go to do the audit.
The speciality we are working on right now is pain management and neurosurgery.

We are confused on the number of diagnoses or treatment options in the MDM section. Let's say that the Dr has indicated two dx's Lumbar spinal Stenosis (724.02) and Lumbar Radiculopathy (724.4) Do you count that as two dx's or would that be just one problem and only counted as one? The patient is established and she is being seen for a follow-up on back pain. The the problem is established to the examiner and is improved or stable. So would we give points to both the 724.02 and 724.4 giving the Dr. a point on each?

Any advice would be greatly appreciated.

Thank you,

Vanessa

[drspatil]

Hi Vanessa,

We need to count both diagnosis for MDM.

Originally Posted by Vanessa123

Another coder and I from my office have been asked to do an internal audit on a couple physicians in our practice. We are both unfamiliar with the auditing process and have many unanswered questions. We are looking for any kind of help we can get. We have the the 1997 guidelines auditing tool and we have watched the E/M video on E/M university. These are all helpful sites but we still get stumped when we go to do the audit.
The speciality we are working on right now is pain management and neurosurgery.

We are confused on the number of diagnoses or treatment options in the MDM section. Let's say that the Dr has indicated two dx's Lumbar spinal Stenosis (724.02) and Lumbar Radiculopathy (724.4) Do you count that as two dx's or would that be just one problem and only counted as one? The patient is established and she is being seen for a follow-up on back pain. The the problem is established to the examiner and is improved or stable. So would we give points to both the 724.02 and 724.4 giving the Dr. a point on each?

Any advice would be greatly appreciated.

Thank you,

Vanessa