Wiki MDM - # diagnoses/mgmt options

[j.berkshire]

I am interested in hearing some input from this forum. When determining the MDM and assigning the points for diagnoses/mgmt options, how do you score a new cyst, rash, etc? Would you score this as a self-limited problem worth 1 point, or a new problem with no additional workup worth 3 points? Thanks for any and all discussion.

 

[FTessaBartels]

It depends

Well ... it depends ....

I look at the documentation as a whole. If there was any lab work or Xray, or the treatment include Rx or advice on what to watch for (i.e. cyst ... increased swelling, decreased range of motion, fever, pain, etc) then I consider it a new problem without additional work up. If the physician examined patient and records something like, "This should resolve in a few days; call if problems" then I consider it self-limiting.

Hope that helps.

F Tessa Bartels, CPC, CEMC