"Decision regarding hospitalization" MDM

jewlz0879

True Blue
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Richardson, TX
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Comprehensive Hx
Comprehensive Exam
MDM
1) Undiagnosed new problem, 2 stable chronic illnesses, Chronic illness with severe exacerbation
2) Data - 5 points
3) Rx drug management

Would you consider: recommend 23 hour obs to ensure no acute coronary artery syndrome w/ troponin q 3 hrs - Decision regarding hospitalization?

I found this and it was helpful but wanted additional opinions. https://namas.co/how-and-when-to-credit-decision-regarding-hospitalization/

I appreciate any feedback.
 

natashalage

Networker
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Walnut Creek, CA
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Hi there :)
I am a new coder and still learning but I will post my thought to continue this dialogue. Per new outpatient guidelines, in our case we have High level for Dx, for Data.. you said 5 points but we don't go by points anymore. For Extensive Level we should have Two out of 3 data listed ( pls see the 2021 table). For MDM, we have drug management which is Moderate risk or High if hospitalized. To my opinion, MDM is moderate based on Rx. I read that Observation is considered as Outpatint service, so to me it's not actually Inpatient admission. Conclusion: Dx is High, Data-?, MDM-Moderate. E/M level depends on Data level.
I just edited my post. To my understanding, New 2021 CG apply only to outpatient E/M and not observation. So 'hospitalization' is not a factor for MDM here.
 
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