We are presently doing an internal E/M audit for our Orthopaedic office and educating our providers. One of our physicians had a question about DME items as treatment and where that falls on the MDM risk table.
He treated an established patient for Achilles tendinitis and Haglund's deformity. His HPI and Exam were both a Detailed level. The patient was given home exercises and a walking boot. The patient has had pain/discomfort with this foot for 1 year. He also ordered an MRI for the heel to evaluate calcium deposits of the tendon. The auditor chose Low for MDM but the provider feels that a walking boot would be like a cast and should be Moderate.
I am needing further guidance for DME/walking boot items and where they fall on the MDM risk table so I can re-evaluate this case for the provider and provide education for everyone involved.
Thank you
Vicki Massey, CPC
Orthopaedic Sports Medicine Center, Inc
He treated an established patient for Achilles tendinitis and Haglund's deformity. His HPI and Exam were both a Detailed level. The patient was given home exercises and a walking boot. The patient has had pain/discomfort with this foot for 1 year. He also ordered an MRI for the heel to evaluate calcium deposits of the tendon. The auditor chose Low for MDM but the provider feels that a walking boot would be like a cast and should be Moderate.
I am needing further guidance for DME/walking boot items and where they fall on the MDM risk table so I can re-evaluate this case for the provider and provide education for everyone involved.
Thank you
Vicki Massey, CPC
Orthopaedic Sports Medicine Center, Inc