trarut
True Blue
Help! I'm having a debate over how MDM was scored for a recent visit that boils down to where and how to credit for a biopsy done during the visit.
Patient presents for a follow-up visit for her recent vulvar cancer, notes during ROS that she has a new lump in the mons. On exam, the physician notes two questionable areas and does a punch biopsy of of the mons and left groin.
Diagnosis - 1 established stable, 1 new problem with workup
Data - 0 points, no data was reviewed
Risk - Moderate (one chronic stable problem and one undiagnosed new problem with uncertain outcome, skin biopsy, no management options)
Would you consider the decision to take the biopsies as workup for the new problem? The coder has scored this as level 4 MDM while the physician says level 3 MDM. I think the physician is not giving himself enough credit but want other opinions.
Thanks!
Tracy
Patient presents for a follow-up visit for her recent vulvar cancer, notes during ROS that she has a new lump in the mons. On exam, the physician notes two questionable areas and does a punch biopsy of of the mons and left groin.
Diagnosis - 1 established stable, 1 new problem with workup
Data - 0 points, no data was reviewed
Risk - Moderate (one chronic stable problem and one undiagnosed new problem with uncertain outcome, skin biopsy, no management options)
Would you consider the decision to take the biopsies as workup for the new problem? The coder has scored this as level 4 MDM while the physician says level 3 MDM. I think the physician is not giving himself enough credit but want other opinions.
Thanks!
Tracy