Advanced Search

Urology Coding Alert

READER QUESTIONS:

Know the Basics of Medical Decision-Making

Published on Sat Nov 05, 2005

Question: When reviewing data for the third key component, medical decision-making, should I count each blood study my doctor ordered as one unit and can I count each particular tracing that my doctor read as a separate unit? Also, is an ordered urine culture and sensitivity considered a "further workup" in deciding the "diagnostic" level of care?


Rhode Island Subscriber
Answer: In calculating the data portion of the medical decision-making (MDM), you should count each of the various studies that you do in one category only once. Laboratory studies such as a urinalysis, creatinine, and electrolytes that your physician orders count only as one point for laboratory studies.

Also, simultaneously reviewing a urodynamic tracing, CT scan or an IVP counts as only two points for "personal interpretation" of a study, tracing or radiological films.

If the patient needs further evaluation for the urologist to determine the correct diagnosis, such as a urine culture for a suspected urinary tract infection (599.0, Urinary tract infection, site not specified), you can consider this "further workup" when determining a diagnostic level.
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in your eNewsletter
  • 6 annual AAPC-approved CEUs*
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more
*CEUs available with select eNewsletters.

Other Articles in this issue of

Urology Coding Alert

View All