Wiki Medical Decision Making

[millbj]

Need Help for MDM level:

Uro provider seeing new pt:

New dx with addt'l follow up planned (coming back for Prostate Needle bx)
UA done
Dx Elevelated PSA- scheduled to come back and have a Prostate needle bx in office- Elevated PSA- options/risk discussed. I consider this Moderate..provider is considering it HIGH. Which level would any other coders/auditors feel this RISK would be?

Thank you

 

[thomas7331]

Just from what you've said, based on guidelines this is moderate risk (using 'undiagnosed new problem with uncertain prognosis' from the presenting problem category and/or 'deep needle or incisional biopsy' from the diagnostic procedure category in the table of risk) unless the provider has documented additional problems, comorbidities or other risk factors that would warrant assigning a higher level. Have you asked the provider why they consider it high risk?

 

[torresjeffreyp@gmail.com]

Teaching and Resident Physician's Diagnoses

Hi, Guys!

Need your thoughts about this scenario: Say for example the Resident Physician documented the diagnoses of URI, Bronchiolitis, Cough and Nasal Congestion..then the Teaching Physician after making an attestation just mentioned the URI and Bronchiolitis as DDx and just documented the Cough and Nasal congestion as his final DX. Is it OK to still code the URI and Bronchiolitis? Or just code the DX by the Teaching Physician? Is it always safe to only code the Teaching Physician's DX in cases where the Teaching and Resident Diagnoses didn't agree? TIA!