Wiki Diagnosis Points

[KaylaRieken]

When a physician lists this:
1. Prostate Cancer
2. Renal Mass
3. Elevated PSA

Would I count each of these as 1 point, or would the elevated psa be a sign/symptom under prostate cancer and this would only be 2 points? (all listed diagnoses are established/stable)

 

[KaylaRieken]

Here I am again with the same question.
1. History of Prostate Cancer
2. Rising PSA following treatment for malignant neoplasm of prostate

Any advice would be greatly appreciated. I am just confusing myself.

 

[thomas7331]

Here I am again with the same question.
1. History of Prostate Cancer
2. Rising PSA following treatment for malignant neoplasm of prostate

Any advice would be greatly appreciated. I am just confusing myself.

I think I would give this two points for an established problem (prostate CA) that is worsening (as evidenced by rising PSA). Sometimes there isn't a right or wrong answer on MDM, though, and you just have to use your judgment based on the context of the whole note.

 

[KaylaRieken]

That's where my thoughts were leading me too. If this would be a new patient that was referred in the MDM table could you consider this a chronic illness with progression in the presenting problem column?

 

[thomas7331]

That's where my thoughts were leading me too. If this would be a new patient that was referred in the MDM table could you consider this a chronic illness with progression in the presenting problem column?

It would depend on your payer's interpretation of the guidelines. I've seen new problems counted by some payers as new to the provider while others consider it new only if it is new to the patient. The MAC where I work goes with the latter interpretation, which I agree with because the MDM is understably lower if the patient has an established history of treatment for a problem, even if a particular provider is seeing them for the first time.