1. P

    Medical Decision Making Risk: Morning after pill (Emergency Contraceptive)

    Hello, We are a family planning specialty. Hope I could get a clarification on the MDM risk when provider prescribes a morning after pill (1 tablet). Is this considered as prescription management? Is truly managed when it is considered an emergency contraceptive and not for recurrent use? And...
  2. G

    Home Exercise Programs (HEP), level of Risk?

    Good morning everyone, Thank you in advance for any possible assistance, but my team and I are a little on the fence regarding level of Risk for HEP's (under Office, 2021 E&M Guidelines). Can someone please help identify or comment on if you would consider indications of "continue/begin home...
  3. J

    Wiki Prescription Drug Management

    Hello all, I have a question in regards to prescription drug management for MDM purposes that myself and other coders in our department have been questioning back and forth for a few months. We work exclusively in the domiciliary and home setting (95/97 guidelines). The patients our providers...
  4. V

    Question Medical Decision Making Table (Number of DXs or Treatment options, DATA Reviewed, and Risk table) Examples for Inpatient Hospital Coding 99221-99239?

    Hi, I wanted to ask if someone can provide me with some links or websites or anything really, that may have a list of common illnesses/injuries that are good examples to use for the different levels of the MDM table for Inpatient Hospital Coding (99221-99239) For example, just like on the Risk...
  5. KStaten

    Recommendation for Dental prophylaxis Following Joint Replacement- MDM

    Hello, Everyone. :) Dental prophylaxis is often recommended for patients following joint replacement, whereas any vulnerable areas for infection in the body can pose a potential risk. If, however, the doctor documents-- in a routine, yearly exam-- that there are no problems with the...
  6. J

    Wiki E/M Risk billing

    We saw a patient for f/u on a fracture. The cast was removed, but he fitted her with a material splint along with the counseling that goes with it. Also, did an order for x-ray. Would this be a 99213 or 99212? I am confused what the risk element would be for splint fitting and fracture f/u...
  7. J

    Atherosclerosis and Angina

    I was researching the code for atherosclerosis with angina. Per the ICD-10 manual appears the correct diagnosis code would be I25.9 Chronic Ischemic heart disease, Unspecified which is not associated with an HCC. Is that correct?
  8. A

    HIGH Risk MDM for IV Morphine in the ED (discharged, not admitted)

    Pt presents to the ED with hand pain. ED provider orders Xray which confirms fractured metacarpal. Provider performs a closed reduction/splint application with no documentation of the patient having to f-u with an ortho for additional casting. Gives the patient IV Morphine and IM Diazepam "FOR...
  9. P

    Visit before Cardiac Cath

    We have had a discussion with one of our doctors so trying to find a clarification. For the visit that a catherization is scheduled and they discuss the general risk of procedure do you classify that under Moderate or High Decision Making? For the risk it is determined by the fact whether or...
  10. S

    Wiki level of risk

    Could I get some opinions please? Note says: Surgical procedure for resection of plantar calcaneal spur is explained to her in detail.* Surgery is not recommended as of yet. Does anyone else think that the "surgery is NOT recommended" part cancels out the Moderate level of risk that would be...
  11. W

    Icd 10 for 2 vessel cord ultrasound & maternal history codes

    Hello, I am new to OB coding and really could use some input. We have several patients receiving serial ultrasounds and BPPs recommended by Maternal-Fetal Medicine due to dx of 2vessel cord. Of course there is no exact ICD10 code for this condition for maternal care. I've looked at 2...
  12. A

    Rheumatoid Arthritis: is it considered a High risk on the Risk Table?

    Would Rheumatoid Arthritis be considered a chronic illness on the high risk portion of the risk table? other examples of high risk illness would be helpful as well. Thank you
  13. L

    high risk pap - Medicare

    When we had a pt who was high risk for cervical Ca in ICD-9, Mcr told us to use V15.89 dx code. I'm trying to find the conversion code to ICD-10. I tried using V92.89 which was my coding software's conversion, but Mcr denied it. Does anyone know where to find high risk I-10 code on CMS...
  14. A

    Does referring to a specialist or a "Consult" counts for "additional work up" ?

    Does referring to a specialist or a "Consult" counts for "additional work up" ? Does referring to a specialist or a "Consult" counts for "additional work up" when leveling e/m visits? and also what are some examples of "drug therapy requiring intensive monitoring from physician in the "risk"...
  15. E

    Wiki History of Polyps - Need some input please

    Need some input please; If a patient comes in for a colonoscopy, non-Medicare, with a history of polyps (tubular adenomas)last colonoscopy over 10 years ago, is this an average risk colon screening or a surveillance colon? Is there any where that states if a patient has not had a colon in over x...