Wiki MDM - High Risk Presenting problem

[prirs1985]

Under MDM, weakness is considered as high risk presenting problem. Does this refer to R53.1 (weakness) or M62.81 (muscle weakness - generalized)?

 

[thomas7331]

Under MDM, weakness is considered as high risk presenting problem. Does this refer to R53.1 (weakness) or M62.81 (muscle weakness - generalized)?

In the table of risk, 'weakness' is only mentioned as high risk in the context of being an example of 'an abrupt change in neurological status'. I would not assign high risk to weakness by itself unless the documentation supports that it is a potential sign of a high risk problem. As the guidelines state, "Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one." It is really up to the provider to document the level of risk - it can't be determined simply by any given diagnosis code.