Wiki Incidental finding and MDM.

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Sarah Ann

Sarah Ann

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I was asked why I didn't code an incidental finding (not treated addressed on the DOS
According to the coding clinic
3rd Q2010 pp 8-9- incidental findings are not coded.
I was told that does not mean you can't add it to the MDM. Any thoughts on how I would do this? I would think there would need to be an assessment/plan.
 
I was told that does not mean you can't add it to the MDM.
Click to expand...
What does that mean "can't add it to the MDM"? What that sounds like to me is considering that incidental finding in choosing the coding level of the visit, like the number/complexity of the problem(s) addressed.
 
Exactly. "It's inappropriate to report an incidental finding found on a rad. report when the finding is unrelated to the sign or sx, or the condition that necessitated the performance of the test for a patient being seen in the ER- the provider would need to clarify the finding was clinically significant and related to the visit in order to be coded"-
I was asked why it wasn't coded, I sent this AHA coding clinic as my reasoning for not coding it.

I was told, "this coding clinic says it is not coded, for the encounter, but it does not mean not to add it to the MDM". o_O I thought I was missing something.

That did not make sense at all so that's why I posted the question- confusing I know.
Thanks!
 
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Is this facility or pro-fee E/M doctor's visit coding?
If for the doc, did they comment on it, treat it, include it as part of their documentation, add it as a assessment/diagnosis for the visit, indicate it somehow impacted their care/treatment of the patient?
Did it only appear on a separate radiology report as incidental?
 
amyjph said:
Is this facility or pro-fee E/M doctor's visit coding?
If for the doc, did they comment on it, treat it, include it as part of their documentation, add it as a assessment/diagnosis for the visit, indicate it somehow impacted their care/treatment of the patient?
Did it only appear on a separate radiology report as incidental?
Click to expand...
This is a pro. fee for an office visit. Yes the provider stated the radiologist noted an incidental finding of a thyroid nodule. The pt is being treated for a fx of the arm.
 
I agree with you and @carlystur.
This part does not make sense to me either: "but it does not mean not to add it to the MDM". I would need more of an explanation of the viewpoint here.
It would not seem to be a problem addressed. It doesn't go in the data column, and how would that go to the risk/management column if they did not discuss, treat or otherwise manage it?
 
Thank you-
Those were my original thoughts(to not work it into my MDM- but I just put the question out there thinking I was missing something because I couldn't figure out why I was asked to work this into my MDM.
 
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