Wiki Considering high risk based on rule out condition or differential diagnosis

debipbarik

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Hi All,

I have a question regarding consideration of rule out condition while deciding high or moderate risk.
Can we always consider risk level based on differential diagnosis or rule out condition?

Example 1: Patient came with testicular pain. Ultrasound performed to rule out testicular torsion. Final diagnosis made bilateral hydrocele. What risk(moderate or high) we will consider for MDM.

Example 2: Patient came for chronic abdominal pain. Performed CT abdomen. Differential diagnosis: SBO and ileus. Past medical history include surgery for bowel obstruction 3 years back.
Patient discharged with abdominal pain diagnosis. No Medication given. Home medication includes losartan 100 mg.

Note: There are no other work up for both example.

It would be appreciable if anyone can help with deciding RISK for medical decision making. Also if anyone can share any guidelines or directive to consider DDx as deciding factor for RISK level would be helpful.
 
From the official CMS E/M guidelines:

"Risk of Significant Complications, Morbidity, and/or Mortality The risk of significant complications, morbidity, and/or mortality is based on the risks associated with these categories:
  • Presenting problem(s)
  • Diagnostic procedure(s)
  • Possible management options
The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next encounter. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk. The level of risk of significant complications, morbidity, and/or mortality can be:
  • Minimal
  • Low
  • Moderate
  • High
Here are some important points to keep in mind when documenting level of risk. You should document:
  • Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality.
  • The type of procedure, if a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter.
  • The specific procedure, if a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter.
  • The referral for or decision to perform a surgical "
While I do not see any direct reference to ruling out or differential diagnoses, both of these concepts are hypothetical. We wouldn't code actual diagnoses on DDx or R/Os either. For this reason and above, I would not even consider the rule out diagnoses or DDx towards any E/M portion.

Hope that is helpful!
 
Hi All,

I have a question regarding consideration of rule out condition while deciding high or moderate risk.
Can we always consider risk level based on differential diagnosis or rule out condition?

Example 1: Patient came with testicular pain. Ultrasound performed to rule out testicular torsion. Final diagnosis made bilateral hydrocele. What risk(moderate or high) we will consider for MDM.

There are three parts or factors that need to be "added up" to get MDM for the encounter.
Diagnosis/Treatment options: 3 (New condition, no further work-up planned)
Data: 1 (Ultrasound)
Table of Risk: Low (Acute uncomplicated illness)

If you add all of these three up, the MDM for the visit would be "Low"
If this were a communicating hydrocele which could lead to a hernia, then on the Table of Risk you could choose "new problem with uncertain prognosis" which is under the "Moderate" level. That would raise the overall MDM of the visit to Moderate.

I hope this helps, any additional input could be beneficial.
 
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