Wiki Determining # of dx in MDM

[BCJ927]

Can an extra point be counted in the number of diagnoses/treatment options section if a provider only states to continue the same medication and dosage for a different problem? For example, a patient came in for a check up and needed to have his meds changed for his bipolar disorder since it was worsening. Would an additional point be added for hypertension as a stable established problem if the medication for that was continued at the same dosage?

 

[AuntJoyce]

# of dx in MDM

If the patient's blood pressure was taken and your doc made the decision to maintain the dose based on that reading, then hypertension was addressed and you sure can claim it.

Happy Holidays!

Joyce

 

[BCJ927]

Thanks for the response. It makes sense, but what about a diagnosis that wasn't addressed in the HPI or exam? We sometimes see an illness or medication in the past history section, but the provider only notes to continue the medication in the MDM.

 

[AuntJoyce]

Diagnoses in MDM

I would then err on the side of caution. If the physician did not directly address the diagnosis...no exam, no updated history but just causally mentioned to continue the medication, let it go. Best to be safe than to be sorry. For some odd reason, coders seem to wear a big old target on their backs and the insurance companies are armed with the bows and arrows.

Good luck!

Happy New Year

Joyce

 

[BCJ927]

Thanks again, I appreciate the feedback.

 

[AuntJoyce]

My pleasure

 

[LTibbetts]

Read your ICD-9 Coding Guidelines, Section IV - under outpatient coding guidelines. Always check your guidelines when in doubt!