Question MDM Risk?

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Hello Everyone ,

Can any on please tell me If patients is coming with Rectal bleeding in office visit and colonoscopy procedure consent is taken then what will be the MDM risk for this? We are taking this as High Risk because of Rectal bleeding with procedure consent. Please advise
 

thomas7331

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Hello Everyone ,

Can any on please tell me If patients is coming with Rectal bleeding in office visit and colonoscopy procedure consent is taken then what will be the MDM risk for this? We are taking this as High Risk because of Rectal bleeding with procedure consent. Please advise

Unless the physician has documented some specific risk factor that you haven't mentioned here, I could consider this moderate risk since the colonoscopy falls under the category of "Diagnostic endoscopies with no identified risk factors".
 

Mayzoo

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Hello Everyone ,

Can any on please tell me If patients is coming with Rectal bleeding in office visit and colonoscopy procedure consent is taken then what will be the MDM risk for this? We are taking this as High Risk because of Rectal bleeding with procedure consent. Please advise

Probably a dumb question, but was the procedure performed, or just consent for the procedure given?
 
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Unless the physician has documented some specific risk factor that you haven't mentioned here, I could consider this moderate risk since the colonoscopy falls under the category of "Diagnostic endoscopies with no identified risk factors".
Thank you for the reply ,can you please explain exactly what type of Risk factor you are talking about ,any example cause in our Physician's MR documentation part is not that much good .we really need to struggle many times.
 

thomas7331

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Thank you for the reply ,can you please explain exactly what type of Risk factor you are talking about ,any example cause in our Physician's MR documentation part is not that much good .we really need to struggle many times.
A risk factor is an additional factor in the patient's history or current condition that presents additional risks to performing a particular procedure.

For example, for purposes of considering the risk of a procedure, a patient that is on anticoagulant therapy could be at increased risk for bleeding, or a patient with chronic lung or kidney disease could be at increased risk for complications under general anesthesia. The provider would need to indicate this in their assessment to warrant assigning a higher level of risk. The normal risks associated with procedures that are routinely given to all patients as part of consent are not the risk factors considered in the MDM, which should be specific to the patient and the encounter.

Similarly, if you are considering the risk of the patient's condition - the bleeding itself in this example - if it is a minor bleeding that is not threatening the patient's life, then the risk is lower than if the patient is having bleeding to a degree, for example, that is causing anemia requiring hospitalization and/or transfusions.

MDM and especially risk is a struggle for most coders because it often requires a certain clinical judgment and doesn't always fall easily into one category or another, and the guidelines are only there to guide you - they can't always give you a definitive right or wrong answer. But you can only go from what is documented in the record and the provider has some responsibility to give their assessment of what the patient's risk is.
 
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Mayzoo

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"High MDM" is when here is a high risk of the patient losing life, limb, organ or organ system without treatment. This is a diagnostic test, not treatment. So without significant identifiable risk factors this is not High MDM.

I am still learning, so this prompts me to ask if discussing the test and getting a signed consent (not performing the test) even factors into MDM? I completed the CEMC course a few months ago and my vague memory tells me merely discussing a test and getting consent does not really count for much in MDM, so is my memory correct?

ETA: It looks like it adds 1 point to the MDM.
 

Orthocoderpgu

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Don't worry all of us are still learning too. Discussing the test and getting consent does not factor in to MDM. Thy physician that makes the decision that the test needs to be done can get credit for MDM. Thomas pointed out that there could be "Risk Factors" since the patient will need to have anesthesia. Is the patient healthy? Common risk factors frequently involve the cardio and respiratory systems. Patients frequently have to stop medications before getting these procedures, making the procedure more risky to perform especially if the medications deal with heart and lung issues. These sort of things would be factored in by the physician that identifies the need to have the test performed.
 

jeskla

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Struggling this week to explain to my docs that "identified procedure risk factors" doesn't mean the normal risks associated with procedures that are routinely given to all patients as part of consent are not the risk factors considered in the MDM . I've had two docs point out that the new MDM table specifically states patient risk factors and also specifically states procedure risk factors.
• Decision regarding minor surgery with identified patient or procedure risk factors
• Decision regarding elective major surgery without identified patient or procedure risk factors

Any suggestions?
 

Orthocoderpgu

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Your NOT under the "new" MDM rules yet. There is always a risk putting someone under anesthesia for a procedure to be performed. But some patient's have cardio or respiratory medical conditions that make putting the patient under anesthesia much more difficult. If you have a heart arrhythmia medical condition, that is going to be much more challenging to put them under without incident than a patient with no heart conditions. There are more health risk factors than heart and lung but those are the most common. And getting the patient to sign the consent form has nothing to do with MDM.
 

jeskla

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Your NOT under the "new" MDM rules yet. There is always a risk putting someone under anesthesia for a procedure to be performed. But some patient's have cardio or respiratory medical conditions that make putting the patient under anesthesia much more difficult. If you have a heart arrhythmia medical condition, that is going to be much more challenging to put them under without incident than a patient with no heart conditions. There are more health risk factors than heart and lung but those are the most common. And getting the patient to sign the consent form has nothing to do with MDM.
I should have mentioned this is for provider training for the 2021 changes...
 
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