MDM; what level


True Blue
Lithonia, GA
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Can someone guide me as to where this note falls under with 1) Number of dx's or treatment options. 2) Risk of complications

New patient 99205 billed. I'm stuck on the MDM

71-year-old gentleman with metastatic prostate cancer with osseous metastases. His recent MRI does show epidural extension of disease at T5. A compression fracture at T8 is also noted. In this case, a course of palliative radiotherapy is recommended, consisting of 3000 cGy in ten divided fractions of 300 cGy each. T3 through T9 will be included.

The risks and benefits of palliative radiotherapy were reviewed in detail with the patient. He has expressed a good understanding and willingness to proceed accordingly. Informed consent has been obtained.
Milwaukee WI
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New patient

Since you are coding for a new patient, by definition these are new problems (to MOST carriers .... I have heard of at least one carrier who will give "new problem" points ONLY when it is a new problem to the patient)

Okay ...
New problem w/o workup- metastastic prostate cancer = 3 pts
2d new problem w/o workup - compression fracture = 3 pts
For a total of 6 PROBLEM POINTS

And you have metastastic prostate cancer which under the table of risk I would consider as "acute or chronic llness that may pose a threat to life ..." = HIGH risk

So with 6 problem points and High risk you have HIGH MDM.

Hope that helps.

F Tessa Bartels, CPC, CEMC