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Wiki Mdm

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drsunitha

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Hi,

help me getting mdm for the following condition:

1.new problem with additional work up
2.lab.inves.-2+1ultrasound+physician performed the u/s and gave report.
3.prescribed antibiotic

diagnosis: vaginitis

thankyou.
 
# of Dx or Management:
New Problem with additional work up would count 4 points.

Amt/Complexity:
Review and/or order labs: 1 points
Independent visualization of US 2 points
Total 3 points

Level of Risk:
Moderate (prescription management)

OVERALL: MDM is Moderate

Hope this helps.
 
If you are billing for the professional component of the US, you may not count the independent visualization of the US in the Amt/Complexity of Data Reviewed. In this particular scenario, the MDM wouldn't change if only 2 total points were given for the review/order labs and review/order radiology tests.

https://www.highmarkmedicareservices.com/em/independent-visualization.html

If the provider is billing separately for the interpretation of a test in the radiology and/or medicine section of the CPT, then that same physician should not take credit for the independent visualization of that test in the Amount and /or Complexity of Data Reviewed Section of the Medical Decision Making key component of an E/M.
 
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