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DNR orders and level of medical necessity

R

Rita B. Conley

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31
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Lebanon, New Hampshire
I have an interesting question that I would like clarification/opinions on. In table C of the audit tool (Risk of Complications/Morbidity/Mortality), under the "Mgmt Options" column and then under the "High" level, the "Decision not to resuscitate or de-escalation of of care because of poor prognosis," needs further clarification.

What level of medical necessity would you think is appropriate if during an out-patient office visit a patient is simply stating as part of his/her advanced directives that he/she would not want to be resuscitated, etc., so a DNR/DNI order is written and signed by the PCP. In this situation, and depending on how many presenting problems the patient has, I could see a low to moderate level in table C.

On the other hand:confused:, if the patient were extremely ill and at the end of his/her life and the decision to de-escalate care, etc., is made, I could understand checking off a high level under management options.

There is a ton of stuff out there surrounding DNRs, etc., but nothing I could specifically find related to coding and level of medical necessity supported.

Can I get anyone's thoughts and/or opinions??
 
Given that it is not necessary to use all portions of the MDM to determine level of service, and as MDM/Medical Necessity must support the overall level of E/M...here are my thoughts:

The High level in the table of risk involves de-escalation of care - meaning the patient and/or patients family have determined that they no longer wish to persue curative therapies and instead are focused on comfort cares/end of life cares. In other words, the patients death is imminent - thus has a high risk for mortality.

When the patient is *not* acutely ill, and is, instead, planning for the future (by signing and providing their PCP with their living will etc.) it would not be a high risk and most likely the balance of the E/M would not support high risk.

Hope this helps!
 
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