Wiki Assessment and Plan MDM

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I have a physician that states in his medical record......

Assessment

New Problems
HIDRADENITIS SUPPURATIVA (ICD-705.83) --


Prescriptions written today:
DICLOXACILLIN SODIUM 500 MG CAPS (DICLOXACILLIN SODIUM) one po bid for 14 days. #28 x 0, 12/07/2009


I need a second opinion, he only tells me he is giving the patient a prescription and nothing else Would you still bill this with Moderate MDM because he is writing a prescription.
 
MDM needs TWO components

To arrive at the correct level of MDM you must meet (or exceed) at least TWO components:
Problem points
Data points
Risk

You have a new problem with no additional work-up = 3 points
You have prescription drug management = moderate risk

This adds up to Moderate MDM

I am hoping you have a history and/or exam somewhere as well, in order to arrive at the correct E/M level.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
audit E&M

Tessa,
I have been looking at quite a few different E&M audit tools lately and I was just wondering which one that you prefer. I am finding that they all differ slightly and I am somewhat confused as to which one would suit me best. I just want to make sure that I am being consistent but I also want to code properly and be confident with the codes that I choose.
And, Deb Mitchell, if you're out there, I would really like your opinion on this as well. Thanks ladies:)
 
Which tool to use

Leslie,

Like many auditors I have accumulated various versions over the years. Most of them are similar but might just be organized on the page a bit differently. Generally they are based on the Marshfield tool.

And, of course, it depends on whether they are geared for 1995 or 1997.

I'm thinking that's not too helpful. But then again, nothing about E/M is an exact science.

F Tessa Bartels, CPC, CEMC
 
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