MDM Help

Coder.Melisa

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18
Location
Phoenix, AZ
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I am not sure that this counts as a High Complexity and any feed back would be greatly appreciated. :eek:

The records read as such and this is a New Patient.

Assessment
IMPRESSION:

1. Severe low back pain with leg and knee pain.
2. Lumbar radiculopathy.
3. Very severe central canal stenosis L45 and bilateral neural foraminal stenosis.
4. L5S1 left neural foraminal stenosis.
5. L34 disc protrusion, facet arthropathy, and bilateral neural foraminal stenosis.
6. Status post knee replacement.

Plan

The MRI results were reviewed in detail with the patient. The patient is suffering from severe low back pain with knee and leg pain secondary to
lumbar spine pathology. Conservative medical management including the use of rest, tylenol and antiinflammatory medication such an motrin has failed to bring about adequate symptom resolution. Continued conservative medical management was discussed. The patient chooses active treatment. She will therefore be scheduled for low-level lumbar epidural steroid injection as soon as possible. This may take place by way of the L5S1 interlaminar approach. The patient will return to the Pain Clinic after her injection for followup. The patient understands that she is to contact the Pain Clinic if problems or questions arise prior to her next appointment.
 
Last edited:

cjstack

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I would agree. I don't see that this supports high complexity MDM. There is no data documented as reviewed. Risk does not meet high, I see Rx management with an injection, but nothing that would be considered high.
 
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