Wiki ED visit Diagnosis or Management Options

[lhoot]

Good Afternoon,

When determining the type of Diagnosis or Management options for MDM, are all ED visits a New problem with or without workup or if patient comes in for what ends up being diagnosed as a cold or viral URI would this ever be considered a Self-limited or minor problem? (This is for the Diagnosis or Management options, not for the presenting problem for risk.)

Thanks,
Laura

 

[lhoot]

Realized my question had a typo, my apologies. I've corrected the original post.
Laura

 

[SharonCollachi]

I'm still confused as to what you are asking. If you're asking about complexity of Medical decision making, new or not new does not factor into the complexity level. Number of diagnoses is just that, number of diagnoses. CPT does not say whether it is new or established diagnoses.

 

[thomas7331]

The guidelines for MDM in the ED are no different from evaluating MDM in any other location. If the problem, per the provider's documentation, meets the definition of a self-limited or minor problem then you would count it as such under the diagnoses category of MDM. The fact that the patient was seen in the ED does not automatically make the problem of a higher level. A 'cold' is listed in most MDM audit tools as a minor problem, so I would treat it as such unless the documentation indicates that there were potential complicating factors involved that would support treating as a 'new problem' in that category.

 

[lhoot]

My question is specific to the Number of Diagnosis/Management Options in the AAPC audit tool. I've attached it in case anyone isn't familiar with it. On the second page is where the MDM tables are. The first table in the top left is the one I'm referring to. I suppose my confusion is that there are two separate tables that use diagnoses for their calculation. I see where "a cold" is listed in the Table of Risk. The Number of Diagnoses/Management Options table is a separate table and doesn't provide examples of what a self limited or minor problem is in relation to this particular table. This table also includes options referring to New Problems, Established Problems, and Self Limited Problem or Minor (Stable, improved or worsening) option. The Self Limited Problem is not qualified with whether the problem is new or established. My understanding is that ED visits should use the New Problem options. I could see where some issues could be considered self limited, but they would also be new to the provider at the ED. That being said , would the Self Limited Problem option ever be relevant to the ED?

 

[tinaleslie]

I would use the self limited problem option is as a secondary diagnosis. A self limited problem is one that would take care of itself if not treated. When I am coding ED I am primarily looking at is it a new problem or a new problem with more work up, such as admit, transfer, or outside followup in order to obtain a diagnosis. The Dx management options are just one part of the MDM - the data section is the second and the table of risk is the third. there must be 2/3 to acquire the proper level.

if a patient is diagnosed with a cold - J06.9 that would be 3 points new problem no other workup)
If the physician did not do any diagnostic tests(labs, xrays... there would be no data points
the risk table - states example of cold under minimal risk - 1 point (If no meds or anything else was done)

This would drop the MDM down to a straight forward decision making

Here's how it changes

A patient comes in with cold symptoms, I do not count each symptom as a dx. I count it as 1 problem. The physician completes diagnostic test bloodwork and xray. That is 2 data points. He concludes that the patient has bronchitis. (3 points no further work up. He sends the patient home with a prescription of steroids, cough medicine and inhaler, that is moderate level risk

If the same patient comes and the physician consults with another healthcare provider because he sees something suspicious on the xray, and refers him to specialist for further testing, (this would change things
The diagnosis management options now are a 4
the data points are a 4 ( 1pt for labs, 1 point for xray, 2 points for consult)
Risk is still moderate
But the MDM now meets a level 4 - high MDM

Now the level of the visit is still dependent on all three areas: History exam and MDM - they all must match up

Hope this makes sense
T~

 

[lhoot]

tianleslie,
Thank you so much. Your explanation helped. I pretty much understood the other two parts of MDM, just the Dx management options were throwing me off a bit, because in the ED a minor problem would be both a minor problem and a new problem. Thank you, thank you, thank you.
Laura