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Hello Everyone -

I have a question about the Number of Diagnoses or Management Options. My supervisor and I were doing an Audit on one of our Centers and they always seem to get high DX counts. We noticed they were counting "Breast Ca screening - negative today" as a count for DX. We felt this should be under the Data to be reviewed count since it did state in other part of dictation he reviewed it. We are trying to find fact about this. They are stating the terms in the definition, "Number of Management options that must be considered" means they can count this. I felt the term referred to the New problem: additional work- up planned etc. Does anyone have any clarification or better translation on this or if this actually what that means. Makes my brain hurt. :confused: LOL

I typed the example of the Assessment below. They counted 5 on the number of possible diag - est. problem; stable, improved.
thanks in advanced for the help, Really Really appreciate it....
GrInS :p


1. Anal Ca, NED x 5 years, expect cured.
2. Breast Ca screening, negative today.
3. Colon Ca screening.
4. GYN screening N/A status-post hysterectomy.
5. History of osteopenia and B12 deficiency.

1. Follow up p.r.n.
2. Patient to have PCP/other providers handle annual screening.
3. Recommend she continue given excellent performance status despite age.
4. N/A.
5. Followed by Dr. ####.


True Blue
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In my opinion, screening should not be counted in MDM. Screening is a preventive service. E/M codes that have MDM as an element are 'sick' visit codes specifically for E/M of problems/complaints. You can't count preventive services as part of the work of a non-preventive code - they should be coded separately. There are preventive service codes that may be more appropriate to capture that part of the physician's work.
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"The nature of the presenting problem and the medical necessity of the encounter are considered when choosing the appropriate MDM level.

The nature of a presenting problem, as defined by the CPT codebook, is 'a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.'

The overall MDM level is based on three factors:
The number of diagnoses or management options; the amount and/or complexity of data to be reviewed; and the risk of complications and morbidity."

"The number of diagnoses or management options is based on the relative difficulty level in making a diagnosis and the status of the problem. Complete documentation will include when a problem is established and stable or resolving, or when it is inadequately controlled, worsening, or failing to change as expected."

"The amount and complexity of data for review is measured by the need to order and review tests, and the need to gather information and data... Additionally, the provider may review the result(s) of test(s) from the Medicine, Radiology, or other sections of the CPT codebook. In order to receive credit towards the level of E/M, the provider is required to document a summary of the pertinent information found. Simply stating "reviewed" without further documentation is not sufficient to receive credit."

"Risk is measured based on the provider’s determination of the patient’s probability of becoming ill or diseased, having complications, or dying between this encounter and the next planned encounter. Risk indications include the nature of the presenting problem, the urgency of the visit, co-morbid conditions, and the need for diagnostic tests or surgery."

I don't think "Breast Ca screening, negative today." can fall into any part of the MDM. Even if you try to apply it towards data reviewed, there has to a documented summary of the findings and how those findings apply to the presenting problem. Because there is no presenting problem, there would be no reason to review the results, and without a presenting problem, there is nothing to diagnose. :confused: