Hi All,
We have a debate within coders on Scoring method of number of diagnosis or Management option in MDM I.e., Table A of MDM.
If for an established pt, in the assessment if there are 4 diagnosis documented and there is treatment given for only 2 out of 4[Physician documents treatment/plans only for 2 diagnosis], then should we count 4 diagnosis or only 2 diagnosis in Table A.
Ex: All the diagnosis are established for examiner
Assessment :
1. Headache
2. Gastroenteritis
3. Hypertension
4. Hyperlipidemia
Plan : Tramadol for Headache and Provider agrees to order EGD.
We have a debate within coders on Scoring method of number of diagnosis or Management option in MDM I.e., Table A of MDM.
If for an established pt, in the assessment if there are 4 diagnosis documented and there is treatment given for only 2 out of 4[Physician documents treatment/plans only for 2 diagnosis], then should we count 4 diagnosis or only 2 diagnosis in Table A.
Ex: All the diagnosis are established for examiner
Assessment :
1. Headache
2. Gastroenteritis
3. Hypertension
4. Hyperlipidemia
Plan : Tramadol for Headache and Provider agrees to order EGD.