Wiki ED E/M Help

codell84

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I'm struggling with leveling the Emergency Room E/M visits with knowing whether to code the MDM risk as Moderate (Prescription Drug Management or IV fluids with additives) vs High (Parental controlled substances or Drug therapy requiring intensive monitoring for toxicity). Are there any steps to verify the drugs given to patients are indeed Parental Controlled Substances? I'm not able to find an all inclusive list. Any suggestions?
 
My feeling about this, and other may disagree, is that the difference should be based on the documentation in the current encounter and not on a list of medications. A given drug may pose a varying degree of risk based on the nature of the patient's condition and circumstances of the particular treatment. In order to assign a level of risk, the physician must document some kind of indication of what that risk is, either explicitly (e.g. by stating that the patient or treatment is high risk due to...) or inferred from the plan (by ordering frequent monitoring or tests, follow-up visits at short intervals, etc.). Remember that the E&M guidelines (quoted below) state that the table of risk is only a guide and not an 'absolute measure'.

"Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment."
 
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