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msingh23

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Need a better understanding on MDM Work sheet for section "Number of diagnoses OR treatment option":
For the first option "Self-limited or minor(Stable,improve or worsening) this work sheet indicates in colum B for number max = 2 then colum C for points 1.
How this works,any input will be appreciated.

Thanks
 
The max = 2 in Column B indicates that you can only count 2 self-limited or minor problems at the most. The 1 in Column C is the number of points allowed per problem - so if you had 2 self-limited diagnosis then you would multiply that times the 1 and you would have 2 points in Column D.

A new problem without work-up is also limited - to only 1 diagnosis - so the most points you could get for that would be 3. The other columns are not limited to number, so if your doctor was treating 4 established problems that were stable, the points in column D would be 4 or if they were 4 established problems that were worsening, the points in D would total 8.

Hopefully this makes sense! :)
 
Thanks you, appreciate you explaining beyond my question to cover that section, doesmakes sense for me.
Thanks
 
Worsening language - location in report?

Does it matter WHERE in the report the worsening language is found for a particular diagnosis? For example, does it have to be stated in the Assessment where the diagnosis is listed; or can I abstract the worsening language from the HPI (or elsewhere in the report)?
 
We accept worsening if it is clear from the overall documentation that the problem is worsening. IT would be nice if it was clearly stated in the A and P, but this does not always happen.
 
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