MDM, diagnosis points

kmartinez

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I would love some input as I have been told two different things and no research online has helped :(

This is regarding the MDM, Diagnosis/Management points.

If doctor states at the end of his I&P, " I have considered the following conditions, being managed by patient's other providers, during this visit: anxiety and fatigue." -- Can these count as two problem points, one for anxiety and one for fatigue, or does doctor need to state that he has considered the conditions and that they are stable (or whatever the conditions status may be).

I appreciate any input regarding this. New to auditing and little nervous about it :)

TIA
KAM
 

Chelle-Lynn

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If this is the entire statement related to these conditions, than I would recommend that you query the provider for additional clarification. To be considered for Medical Decision Making (MDM) the documentation requires a little more support. You are correct that statement to effect of "stable" would be needed to determine that the physician managed or evaluated the status of the condition.
 
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You would also need to see that each problem is treated or managed in some way.

Per 95 guidelines:
DG: The initiation of, or changes in, treatment should be documented.Treatment includes a wide range of management options including
patient instructions, nursing instructions, therapies, and medications.

For example:

Stable anxiety - Continue 0.5 mg xanax daily
New fatigue: Check CBC, TFTs, ESR
 

Pathos

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You would also need to see that each problem is treated or managed in some way.

Per 95 guidelines:
DG: The initiation of, or changes in, treatment should be documented.Treatment includes a wide range of management options including
patient instructions, nursing instructions, therapies, and medications.

For example:

Stable anxiety - Continue 0.5 mg xanax daily
New fatigue: Check CBC, TFTs, ESR
Agreed, if the provider is just giving you a laundry list of the patient's problems, but did not address each problem, then I would be hesitant to count them towards anything.

Querying the provider when something is unclear is recommended, just be careful you don't ask leading questions.
 

twtcpc

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I would love some input as I have been told two different things and no research online has helped :(

This is regarding the MDM, Diagnosis/Management points.

If doctor states at the end of his I&P, " I have considered the following conditions, being managed by patient's other providers, during this visit: anxiety and fatigue." -- Can these count as two problem points, one for anxiety and one for fatigue, or does doctor need to state that he has considered the conditions and that they are stable (or whatever the conditions status may be).

I appreciate any input regarding this. New to auditing and little nervous about it :)

TIA
KAM
Hello,

I agree from what you have posted that a query to the provider is necessary. It may be that he/she has "considered" the anxiety and fatigue as it may affect how the condition that he/she is treating the patient for by exacerbating it or maybe the treatment for the anxiety and fatigue contradicts the planned treatment for the condition he/she is treating. All of this being said, the provider should be documenting this thought process within the note.

I hope this helps! :)
 
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