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Wiki MDM Question

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coder21

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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!
 
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.
 
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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