Wiki High level urology problems?

[toria11]

Hi all--

I'm wondering what you guys consider high MDM level problems.. The Painters explained that the problem must be of such a severity that the patient needs to be stabilized or immediately taken to the hospital. But what if they are already there? What about an infected stone and the patient is at risk of becoming septic and needs a stent placed? Or possible testicular torsion? Just looking for a thread with some high level urology problem examples. Thanks!!

 

[MrsClin]

Just my thought...
I would review number of complexities, data, and decision making. Meeting the bullet point of any of the two would constitute a the level of decision making. Time can also be used as a factor.

 

[csperoni]

To reach high level for number and complexity of problems addressed, it can be either:

• Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.
• Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity.

In general, it's difficult to say any specific problem is any given level. It all depends on the documentation of the particular patient's case at the time of treatment. You mention the example of possible testicular torsion.
Patient A with possible testicular torsion may be experiencing some mild pain, otherwise healthy, and sent for a sonogram. Stating that problem is high seems like a stretch.
Patient B with possible testicular torsion may be experiencing severe pain, swelling, and fever. That patient is sent to the ER and the urologist calls the ER doc to discuss. Calling that problem high seems appropriate.
Similarly your other example of an infected stone could have factors like a high fever or comorbidities that make one patient more complex than another.

Even a patient with cancer could have problem level of low, moderate or high. And it will fluctuate during the course of illness and treatment depending on response to treatment and side effects.
To me, you have to level each particular service based on the status of the problem at the time of care, not simply by what the problem is.

And as stated by @MrsClin, problem is only 1 of 3 elements to determine the overall MDM.

 

[toria11]

Thank you for your torsion examples! I'm trying to talk about some examples of high level problems. I'm aware that there's more to determine the overall MDM. Problems addressed is the element that I find is the least often at a high level, so I wanted some opinions on what other coders consider high level urology problems.