Low or Moderate MDM for history of CVA, etc?


Local Chapter Officer
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The provider lists 3 Diags:
1) History of CVA w/residual deficit - She is doing very well with no signs or symptoms indicating recent stroke. Her BP within target range, no hx of DM. Meeting target goal for cholesterol. Risk of stroke in the future is reviewed. She will continue current meds.
2) Hemiplegia affecting dominant side - A subtle left hemiparesis persists on her exam. She should continue the exercises previously given to her through PT and OT after her stroke syndrome. No new significant changes are noted and no functional impact is reported.
3) Gait abnormality -Core muscle strengthening measures are reviewed. Appropriate footwear is reviewed. This subtle hemiparetic gait does not require the use of an assistive device at this time.

For Diagnosis points, would this be considered 3 established stable problems or would the gait abnormality be considered a symptom of #2?


True Blue
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I think you could argue this either way, but I think you're basically correct in observing that the gait abnormality is related to the hemiplegia. Based just on what you've said and without seeing the rest of the note, I would be inclined to count this as two problems, and would consider this Low MDM given the bigger picture that the patient is established, documented as being stable with no new problems, no changes in treatment plan and no tests or procedures planned that would involve increased risk.