• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below.
  • We're introducing new features and a new look to make the forums easier to use and more valuable to you. See what's new and let us know what you think!

Question Medical Decision Making for new but minor problems


Best answers
I have chart of established patient with below assessment and plan. Can we consider MDM to high complexity for below example ?As multiple new problems with management are given but these problems may not meet medical necessity for high MDM. Please guide.

Assessment / Plan

Patient with + Influenza A
- Instructed on increase fluids, more rest, and to stay away from work/school/people until 24 hours after last fever.
- Medication below prescribed.
- Patient is allergic to Tamiflu, unable to take
- Return Precaution instructions given to return with worse symptoms, inability to keep fluids down, worsening Shortness of breath, or any other concerns.
1. Influenza-like illness
B34.9: Viral infection, unspecified
2. Fever
R50.9: Fever, unspecified
  • ketorolac 60 mg/2 mL intramuscular solution -
    • Inject 2 mL by intramuscular route. Quantity: 2 mL Lot #: ADM905 Route: Intramuscular Site: Deltoid, Left Manufacturer: ALVOGEN INC Exp Date: 01/31/2021 Administered
3. Acute pelvic pain
R10.2: Pelvic and perineal pain
  • ibuprofen 600 mg tablet -
    • Take 1 tablet(s) 3 times a day by oral route as needed for 10 days. Qty: 30 tablet(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
4. Acute pharyngitis
J02.9: Acute pharyngitis, unspecified
5. Influenza due to Influenza A virus
J09.X2: Influenza due to identified novel influenza A virus with other respiratory manifestations
  • codeine 10 mg-guaifenesin 100 mg/5 mL oral liquid -
    • Take 10 mL every 4 hours by oral route as needed. Qty: 1 118 mL bottle(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
  • fluticasone propionate 50 mcg/actuation nasal spray,suspension -
    • Spray 1 spray(s) every day by intranasal route. Qty: 1 15.8 mL aer w/adap(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
  • Tessalon Perles 100 mg capsule -
    • Take 1 capsule(s) 3 times a day by oral route as needed for 10 days. Qty: 30 capsule(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
6. Nausea
R11.0: Nausea
  • ondansetron 4 mg disintegrating tablet -
    • Take 1 tablet(s) by oral route. Quantity: 1 tablet(s) Lot #: 0d0418014-A Route: Oral Site: Oral Manufacturer: AUROBINDO PHARM Exp Date: 05/31/2021 Administered
  • ondansetron 4 mg disintegrating tablet -
    • Take 1 tablet(s) every 12 hours by oral route as needed for 10 days. Qty: 20 tablet(s) Refills: 0 Pharmacy: WALGREENS DRUG STORE 09709
  • Result:
    - Flu: positive
  • Result Note: Flu type A
  • Results:
    - Leukocytes: Negative- Nitrite: negative- Urobilinogen: .2- Protein: Negative- pH: 6.0- Blood: Negative- Ketone: Negative- Bilirubin: Negative- Glucose: Negative- Appearance: Clear- Color: Yellow- Specific Gravity: 1.025
  • Result:
    - HCG: negative
Return to Office
None recorded.


Best answers
all diagnosis seem to be the result of 5 which in an outpatient setting you wouldn't code signs and system when you have a definitive diagnosis of Influenza, new problem with prescription management but no additional work up planned, I would state MDM is moderate.


True Blue
Best answers
I would agree with modifier MDM here - I'm not sure how you could even count this up to high MDM. Regardless how many diagnoses you count, I don't see any additional work-up so this can't exceed the moderate level in that category. With limited data, and moderate risk, this would equate to moderate MDM.