MDM in ED: Number of diagnoses and management options


Local Chapter Officer
Bonita Springs, Florida
Best answers
Can any ED or E/M coders please point me in the right direction?

I understand that the presenting problem is always new to the provider. However, when there is no follow-up planned beyond this encounter, is the number of diagnoses and management options limited to 3 points? In the rare instance that the ED physician addresses more than one separate and distinct issue (i.e. fracture and hyperglycemia) during the same encounter, and the 3 points for new problem is limited to one occurrence per encounter, can an extra 1 point (as though it was an existing problem) be added to bring this to 4 points for Number of Diagnoses and Management options? I am trying to find a source to support this one way or the other.

Thank you!