MDM help!?

carriganm

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I am have a chart note that I am trying to decide which level of MDM I can use. The patient presents with a new problem to the examiner but it has been treated before by a different provider in a different clinic. The problem is recurring so can I count this as a new problem for 3 problem points and then a chronic illness with mild exacerbation, progression, or side effects of treatment for the risk level?

Thanks!
 
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I am have a chart note that I am trying to decide which level of MDM I can use. The patient presents with a new problem to the examiner but it has been treated before by a different provider in a different clinic. The problem is recurring so can I count this as a new problem for 3 problem points and then a chronic illness with mild exacerbation, progression, or side effects of treatment for the risk level?

Thanks!

Is the other provider/clinic from another group?

For the MDM risk, you'd have to keep in mind the nature of the presenting problem and medical necessity. What condition are you dealing with?
 

carriganm

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It is a recurring lesion that the patient had previously had excised from a different provider from a different office. The current examiner (provider from my office) is now recommending cryo for the patient and referring him to a Dermatology provider.
 
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So your provider's office is not within the same group? A group can contain multiple offices at different sites which is why I ask.

What type of lesion is it? There are so many different kinds that it's hard to really give you an answer. Generally speaking, I don't think a lesion that was removed and has subsequently returned would qualify as a chronic condition. "Chronic condition" usually indicates a long-term condition or disease, such as asthma or HTN or DM.

Can you provide more specifics?
 

carriganm

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So your provider's office is not within the same group? A group can contain multiple offices at different sites which is why I ask.

What type of lesion is it? There are so many different kinds that it's hard to really give you an answer. Generally speaking, I don't think a lesion that was removed and has subsequently returned would qualify as a chronic condition. "Chronic condition" usually indicates a long-term condition or disease, such as asthma or HTN or DM.

Can you provide more specifics?

It is a verruca vulagris lesion.
 
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Gotcha. If you have a wart that is excised, it could very likely return or regrow because the root may not have been removed. Cryo destroys the wart, including the root. My inclination is that this is exactly what is happening - it's just regrowing because the root was not removed.

If I were calculating the MDM for this provider, in the absence of any underlying condition that the wart is manifesting from, I would consider:
- The provider evaluated one specific problem
- The nature of the problem is minor (that the provider didn't order any tests or other workup and didn't provide any treatment immediately)
- The provider did nothing more than evaluate - he/she did not order the cryo; he/she simply referred the pt to a dermatologist for treatment suggesting cryo. It would be up to the derm provider to decide if that's appropriate and how to best treat the problem.

I would choose straight forward for the MDM. (Self limited/minor problem [focus on the wart] with minimal decision making [referring the pt elsewhere]). The derm provider will be the one who will get the higher MDM level because he/she is determining the severity of the problem, reviewing treatment options, and likely will provide some sort of treatment personally.
 
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