Medical Decision Making - Parenteral controlled

Fort Lauderdale, FL
Best answers
Parenteral controlled substances are considered a high MDM, however what about when the drug is administered during a procedure that is moderate MDM? Example: Physician is performing a facet injection on a patient and administers IV versed, can this be considered high, because not all injections are performed with conscious sedation.... Feedback would greatly be appreciated.
well technically you cant base the entire MDM on one thing. what you CAN do is because the controlled substance represents a higher level of risk, you can use the high risk level from the table of risk. then you have to weigh that against the number of diagnoses & treatment options (add them up), and ordering/review of diagnostic tests (reviewing films, ordering labs, etc.; these have point values that add up). then you take the three components of the MDM, find the top two on the table, and figure out your MDM from there. if all three are on different levels, use the middle one. hope this helps! :)
Thank you for your response and I didn't realize that my question made it seem like I was only utilizing the risk section of the MDM. I am aware that I have to select the appropriate level based on 2/3. Your feedback was helpful and I appreciate it.
MDM is based on the E/M documentation

MDM is based on the E/M documentation, NOT on the procedure that followed the E/M.

So I would think that in most cases you will be assigning the risk based on what is documented in the E/M ONLY (e.g. will schedule patient for facet injection).

Hope that helps.

F Tessa Bartels, CPC, CEMC
I must be phrasing my question wrong....I know that MDM is based on E/M only. However, when selecting the MDM you are taking the risks associated with your plan of care and that is what I am referring to.....

Patient A scheduled for a facet injection
Patient B scheduled for a facet injection with IV sedation

The fact that IV Versed is a peranteral controlled substance, does that make the risk of this procedure a high on the MDM table?