Wiki Additional Work-up and MDM question.

[PennyG]

Need opinion on the following Assessment and Plan:

1. Strain of supraspinatus muscle
S46.012D: Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, subsequent encounter
PHYSICAL THERAPY SHOULDER REFERRAL - Schedule Within: provider's discretion

2. Strain of subscapularis muscle
S46.012D: Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, subsequent encounter

3. Chronic kidney disease due to type 2 diabetes mellitus
E11.22: Type 2 diabetes mellitus with diabetic chronic kidney disease
GLYCOHEMOGLOBIN, TOTAL, BLOOD - To be performed on or around 12/08/2018
BMP, BLOOD - To be performed on or around 12/08/2018
LIPID PANEL, SERUM - To be performed on or around 12/08/2018

4. Hypothyroidism -

E03.9: Hypothyroidism, unspecified
levothyroxine 137 mcg tablet - TAKE 1 TAB DAILY MONDAY-SATURDAY, 1/2 TAB SUNDAY Qty: 28 tablet(s) Refills: 1 Pharmacy: CVS/PHARMACY #6510
TSH, SERUM OR PLASMA - To be performed on or around 12/08/2018

Discussion Notes
Will refer to PT and have Pt f/u in the next month. Informed her that an injection was not appropriate this close to the last and would likely not help as she has more than one tendonopathy. Pt given lab order which should be completed the week prior to her next visit.



I am going back and forth as far as counting the Chronic Kidney disease due to type 2 diabetes mellitus and the Hypothyroidism for the Medical Decision Making. There is no HPI relating to either of these diagnoses. Patient came in for the shoulder issue and that is all that is addressed in the History and Exam. It appears the provider ordered the lab work so he would have it for the patient's future visit, and possibly the patient needed a refill on medication. I know I need to query the provider, as need to know the status of each of these diagnoses. However, if the sole purpose was ordering the lab work, do I even need to consider these two diagnoses in the MDM?

Thanks, in advance, for your assistance.

 

[PennyG]

Anyone have any input for this question? Three of us in our office are having this discussion and cannot come to a conclusion.

 

[thomas7331]

Personally, I would count those since the provider is documenting having made a decision regarding these two conditions during the visit, so that does contribute to the complexity of the provider's work. While it's true that medical necessity needs to be supported, there is no written rule or coding guideline that says a provider cannot address conditions that are not specifically mentioned in the HPI or that these should be disqualified from being counted toward MDM, and a provider always does need to consider the entire patient health history in any visit. I would not query the provider for something of this magnitude unless there is a clear error or omission in the note.

Whether or not the provider should have included those problems in their decision making when the HPI does not clearly state so is a clinical judgment and as a coder, I would give the provider the benefit of the doubt that this was appropriate, but perhaps save this example as a discussion point about general documentation improvement to support medical necessity the next time I met with the provider. Just my thoughts and not all coders will agree with me, but if this is an issue specific to a single encounter, keep in mind that you are just looking at one element that plays a role in a single E&M code level which is in the larger picture carries a very minor audit risk and or financial impact for the practice. If you query the provider and/or involve multiple coders in discussions about such details in individual instances, you can end up costing the practice more than you are gaining. However, if you are having ongoing problems with a provider documenting work that has no obvious medical necessity, that is a more broader issue that is better addressed through education sessions or discussions involving the providers rather than through queries or requests to providers to amend documentation.