MDM Question

coder21

Guru
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Patient comes in for a follow up and provider list in assessment:

I25.10
E11.9, uncomplicated
I10

HPI is patient coming in for follow up no chest pain.

8 Physical exams

How would you code this. Do you count the E11.9, and I10 as est problems stable and two stable chronic conditions?

Thank you!
 

thomas7331

True Blue
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There's not enough information here to be able to code anything. There's no way to assign a level of MDM based just on a list of diagnosis codes. The provider would need to at least document the status of the conditions and a treatment plan.

From the 1995 documentation guidelines as pertains to MDM:


DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.
For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.
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.
 

nomerz

Networker
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Agree with the previous reply, the information you gave is too limited... MDM involves risk, meds given, testing done for rule-out/in, consults, etc. If you can give more information that would be helpful. :)
 
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