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Wiki How would you code this regarding MDM?

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kmartinez

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Looking for help regarding this visit and the appropriate E/M level regarding MDM.

Visit has a detailed history and expanded pf exam, and I am thinking a Moderate MDM for a 99214.
My questions are regarding the three elements of MDM.

This is the Impression and Plan Summary:
PAIN IN RIGHT ARM - New.
Orders: US: extremity - right - non vascular.

BICEPS TENDON RUPTURE - New. Ultrasound reveals bicep tendon tear Ortho referral made. May use ibuprofen 800mg PO TID otc prn pain. Medication education provided including possible side effects.

Here are my questions:
1) would the pain in right arm dx count as a moderate level in the table of risk as an Undiagnosed new problem with uncertain prognosis? (Also my boss had mentioned that 2 new problems equal Moderate Risk but I can't find documentation for that)
2) Does the provider get 2 data points? One point for ordering the US for the pain in arm, and one point for reviewing the US for the bicep tendon tear?

I would appreciate any input regarding this to further my knowledge and understanding regarding MDM and this type of scenario.
TIA
KM
 
Based on the documentation I would consider the MDM as:

Dx: New Problem with no additional work-up
Data: X-ray ordered/reviewed
Risk: Low

I would consider the risk low based on the following:

* Procedure Ordered was an ultrasound that would be considered Minimal risk
* Management was with an over the counter medication that would be considered Low risk
* The injury/illness is one acute uncomplicated illness or injury

So the overall Risk Factor would be: Low

The ordering and review of the ultrasound would be 1 point. This is based on the "and/or"
There is only one new condition. The arm pain was determined to be a bicep tendon rupture. This is one condition. Arm pain was the chief compliant the diagnosis is the tendon rupture.
 
Data Points

If provider had a UA done for dysuria as well as a Lab tests such as the CBC, TSH, etc for a family history of hemochromatosis, would these UA and the Lab tests each count as a data point, for 2 points? Or would it just be 1 point?

KM
 
For the data reviewed table it is all or nothing. So if a provider did a UA and ordered a panel, then value would only be one. Same on the other options.

If a provider ordered 3 different x-rays, the value would only be one.
If a provider ordered medical records from 3 different offices the value would only be one
If a provider did an independent visualization of a lab and a xray, the value would only be two (not four).

So like I said it is a either all or nothing. :)
 
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