Counting MDM points

carriganm

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Can you count acute problems as a new problem in the MDM? For example:

HPI:

Pt presents today with c/o poison oak rash. She has used OTC cortisone and calamine lotion and essential oils. She first noticed it on her right arm on Saturday. She was holding and hugging her sister's dogs who had been out in the poison oak. The rash has spread to her left arm, right leg and now on her chin.

Assessment and Plan:
1. Contact dermatitis - Recommend use of caladryl. Rx written for pred pak.
L25.9: Unspecified contact dermatitis, unspecified cause
prednisone 10 mg tablet - Take by oral route. as instructed. See note. Qty: 21 tablet(s) Refills: 0 Pharmacy: CVS 16159 IN TARGET Note to Pharmacy: Day 1: 6 tablets Day 2: 5 tablets Day 3: 4 tablets Day 4: 3 tablets Day 5: 2 tablets Day 6: 1 tablet
 
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Acute problems could be counted as new to the provider, but they would have to require a higher level of risk than what's being treated in this case. This should fall into a self-limited or minor problem. If this was the only problem addressed during the visit, I can't get it counted to anything other than straightforward.
 

carriganm

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Acute problems could be counted as new to the provider, but they would have to require a higher level of risk than what's being treated in this case. This should fall into a self-limited or minor problem. If this was the only problem addressed during the visit, I can't get it counted to anything other than straightforward.

If it can be counted as a new problem, don't I get my 3 problem points and then because the provider prescribed the patient an RX I get my risk points?
 
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The prescription management item is one of those "gray areas" as they say. But you have to remember that you need to look at the overall picture, not just focus on one detail (i.e. RX mgmt). The rule or guideline above all else is medical necessity. Certainly there's a risk inherent in taking any medication, OTC or prescribed. But to what extent, what degree, is the risk for taking the actual drug being prescribed? Can chemo drugs be considered an equivalent risk as antibiotics? That's where you have to go back and look at the nature of the presenting problem. Do any of the other items listed in the moderate section seem applicable to a minor or self limited problem?

To put it another way, let's say a patient is seen post MVA for a follow up regarding whiplash and is prescribed hydrocodone for pain. Is hydrocodone an equivalent to prednisone if you're just looking at prescription management? Hydrocodone is a schedule II drug, a far cry from prednisone; it's highly addictive, has a high potential for abuse, and if taken improperly, could easily cause significant harm to, or death of, the patient. I can't recall ever hearing of a person overdosing and dying from prednisone, if you know what I mean. To make an even clearer point, hydrocodone is in the same schedule as topical COCAINE.

Don't get me wrong, I get what you're saying and I struggled with how to apply the concept for quite a while; it wasn't until I started looking at RX mgmt from the standpoint of its DEA schedule classification and so forth that it started to "click" for me.

Nonetheless, it still boils down to the fact that the problem is self limited and no tests were done; even if you scored a high level of risk, the other two items will trump that and keep the MDM level as straightforward. For this specific case, this specific situation, the RX mgmt is really a non-issue in the end.

I also forgot to mention, that a new problem and a self-limited/minor problem are not synonymous.
 
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There's also this from AAPC:
"According to the CPT® codebook, a self limited or minor problem is, “a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health OR has a good prognosis with management/compliance.”
 
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