"Decision regarding hospitalization" MDM

jewlz0879

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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

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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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Since the new guidelines are only for the office New and Established visits, you would use the 95 or 97 guidelines for this observation admit. If you have a comp hx and comp exam and you meet 2 out of 3 on the MDM table in high - New problem with a work up - 4pt in section A and you have 4 pts or more in section B for data reviewed, then you have a high level MDM regardless of the risk. Hope this helps.
 

csperoni

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My understanding of the original question is that the patient presented to the office, and the OP is trying to determine if the "recommend 23 hr obs" meets the 2021 requirements of high risk.
If that is the question, that statement alone would not support high risk, but could be disputed. If the note further documented observation care vs in patient care, then I would likely credit high risk.
With the information provided, I would level as:
1) High for problem (chronic illness with severe exacerbation) LEVEL 5
2) Moderate for data (assuming 5 data points means ordering or reviewing 5 unique tests not previously counted without independent interpretation or discussion with appropriate source) LEVEL 4
3) Moderate for risk (Rx order or obs) LEVEL 4
The theory of the 2021 outpatient changes is that the provider is getting credit for their actual medical knowledge and decision making vs checking a bunch of boxes in an EMR. The issue now becomes making certain the thought process in the clinicians head is clearly documented in the EMR.
 

jewlz0879

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My understanding of the original question is that the patient presented to the office, and the OP is trying to determine if the "recommend 23 hr obs" meets the 2021 requirements of high risk.
If that is the question, that statement alone would not support high risk, but could be disputed. If the note further documented observation care vs in patient care, then I would likely credit high risk.
With the information provided, I would level as:
1) High for problem (chronic illness with severe exacerbation) LEVEL 5
2) Moderate for data (assuming 5 data points means ordering or reviewing 5 unique tests not previously counted without independent interpretation or discussion with appropriate source) LEVEL 4
3) Moderate for risk (Rx order or obs) LEVEL 4
The theory of the 2021 outpatient changes is that the provider is getting credit for their actual medical knowledge and decision making vs checking a bunch of boxes in an EMR. The issue now becomes making certain the thought process in the clinicians head is clearly documented in the EMR.
Thank you! Correct. I was curious if a statement as the one above would meet requirements of 'Decision regarding hospitalization.' I did not believe it did, so I wanted to see if other coders felt the same.
 
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