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Wiki Medical Decision Making Question

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mlillard

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In an urgent care setting, most of our patients are new patients with a new problem to us. Under number of diagnoses or management options, should it be a multiple (3 points) as a new problem with no additional workup when we are not taking further tests? Example, new patient with ear pain, diagnosis acute otitis media. We prescribed prescription drug for patient. Should this be billed as a moderate complexity since new patient, new problem and prescription drug given? Thanks so much--MDM is very confusing!!!!!
 
Yes since he is prescribing drug management it would be of moderate complexity. And it is a new patient without any further workup.

Hope this helps!

~ Kim
 
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