Mdm

lnaschke

Networker
Messages
41
Best answers
0
I did a chart audit for an established patient yesterday where the components of the MDM were all different:
No of DX or TX options-Moderate
Amt/complexity of data reviewed/ordered-Low
Risk of Complications, Morbidity, Mortality-Minimal

Should I have chosen the lower, middle or higher value?
 

Love Coding!

Expert
Messages
371
Best answers
0
2 of the three or in the middle...

Middle, from what I have been taught. It has to be 2 stacked up or the one in the middle.

I hope this helps!

Denise
 

meganpoelzer

Networker
Messages
62
Best answers
0
Use the highest level

You want to use the highest level circled. If you take a look at the Risk of Complications and/or Morbidity or Mortality table, it specifically says "circle the most appropriate factor(s) in each category. The overall measure of risk is the highest level circled."

Megan, CPC
 

pegasus623

Contributor
Messages
10
Location
Bridgeport, CT
Best answers
0
MDM Criteria

According to the 1995 E/M documentation guidelines:

To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.

So, when you have a bullet in each of the levels, you drop the lowest and go with the midpoint.

Scott
 
Messages
4,466
Location
Milwaukee WI
Best answers
0
Two of the three meet or exceed

Two of the three elements must meet or exceed. You drop the lowest, and then go with the lowest of the ones left.

It would be helpful if you actually told us the number of data points and problem points.

But ....
Problem points: you state "moderate" so I'll assume you mean 3 points
Data points: you state "low" which on my audit tool equates to 1 point
Risk: you state Minimal

So you have two at Minimal or Low and 1 at Moderate.
If you drop the lowest, you still only have 1 at Low and 1 at Moderate so your level of MDM is STRAIGHTFORWARD.


F Tessa Bartels, CPC, CEMC
 

Love Coding!

Expert
Messages
371
Best answers
0
I agree with Scott, I have been taught that if you have...

Number of diagnosis and treatment options, let say (3) for new problem to examiner to additional workup planned

Risk of complications, let's say, ove the counter drugs were recommended = low

Amount and/or complexity of data to be reviewed= 1 (clinical lab tests)

Two of them need to meet or go with the one in the middle...

Is this not correct????

Thanks
 

meganpoelzer

Networker
Messages
62
Best answers
0
Addendum

I do agree with the above. For some reason, I thought you were just talking about the table of risk. You should go for the lowest or the middle in order to ensure "at least two elements must meet or exceed level requirements".
 
Top