Wiki # of Diagnosis or Treatment Options in the ER

[brookeborne]

We all know that in the ED setting that the problem(s) the patient presents with are New to the Examiner (MDM). However, if that patient presents with multiple problems, how would you score this, depending on if the provider had additional work up planned. If no additional work up was planned, does this mean that the provider only gets 3 pts for multiple conditions/problems?

Any thoughts?

 

[Mojo]

We all know that in the ED setting that the problem(s) the patient presents with are New to the Examiner (MDM). However, if that patient presents with multiple problems, how would you score this, depending on if the provider had additional work up planned. If no additional work up was planned, does this mean that the provider only gets 3 pts for multiple conditions/problems?

Any thoughts?

We cap it at 3 points. If we did not limit it to one problem, a kiddo with a febrile seizure discharged with a antibiotic for AOM would be a level 5. I noticed that Novitas and E/M University allow a maximum of 1 new problem to the examiner in their MDM calculator/worksheet.