Wiki level for treatment options

[wynonna]

Hello:
If there is a discussion of treatment options for a chronic problem, but no OTC/RX discussed or tests ordered, can this still be low risk?
ex: continue dirty water precautions, follow up in 7 months. Continue monitoring.

 

[lgardner]

yes. it depends on the documentation (as always), but remember, 2 of the 3 elements must be met to report a level of service.

1 stable chronic dx = low level of problems addressed
based on what you've provided..
0 data reviewed or analyzed = minimal level of data
no or low risk= minimal or low level of risk
________________________
minimal or low level of service

even if there were 2 or more stable chronic dx-

2 or more stable chronic dx = moderate level of problems addressed
0 data=minimal level of data
no or low risk= minimal or low level of risk
___________________________
low level of service

 

[wynonna]

thank you.
This is my question: How to determine the difference between minimal and low level of risk?

 

[Sarah Ann]

Using the new MDM table. Those are examples only. There are no examples under minimal or low- an explanation by the AMA- the pt could have a disease that interacts with taking an OTC- The reason the table is "empty" they want the clinician to use their training and experience to decide what the risk is based on that particular patient. If a coder decides from a table it does not satisfy their requirement. That is my understanding of reading the guidelines- the AMA guidelines (in green, and red.) There's a new coding table that doesn't have things you can select like the 95-97's. Somebody let me know, I may be losing my mind.
You can listen to the webinar at the AMA- it's free you just have to register.