Help with E/M level

mrolf

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Patient is here to discuss the need for a repeat colonscopy. Had one 10 yrs ago. Did have a benign polp that was removed. Risks and benefits of colonscopy were discussed with patient. Hx of HTN, hypercholesterolemia & dyspepsia. Medications were listed & allergic to penicillin. No ROS. History would be Problem focused. We have a expanded problem focused exam documented. Question the MDM. # of Diag points ??????, Data points????
Risk Moderate. Any help would be appreciated. Thanks.
 

MnTwins29

True Blue
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Were old records reviewed to obtain the information about the polyp removed? Was the procedure ordered? And for the Dx points, is the only dx listed the hx of removal of polyps? Was this known before the patient presented?
 

mrolf

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Data points

Nothing was documented that old records were reviewed. Concerning the order - the patient did sign a consent for colonoscopy to be performed which is on the outpatient hospital record, and a IV Sedation form for clearance to have procedure done completed by the doctor and a copy sent to OP dept. Can't find a written order in the clinic chart unless we can count the IV sedation form as a order. It does state on the form: Procedure indicated and the reason for procedure. In the Data Points portion of the MDM there is no points given for order in the surgery section, only the lab, xray & medicine section. Can we still give 1 data point for the order?
Regarding # of Diagnosis: It is not a new problem. Don't really know if it could be an established stable problem because no current problem but has history of benign polyps.
Just confusing.
 
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