Wiki Medical Decision Making

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KaylaRieken

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Number of Diagnoses:
1. BPH with LUTS-stable
2. Frequency-stable
3. Urgency-stable
4. Kidney Stones-stable

How many points is this? Do I count the BPH with LUTS including the frequency and urgency as 1 stable problem? Or do I count BPH with Luts, Frequency, Urgency, and the Kidney stones as 4 points?

Also Would the risk be moderate then if its 2 stable chronic diseases? They are ordering a KUB and reviewed a UA for Data.
 
BPH with LUTS (lower urinary tract symptoms) definition is inclusive of symptoms such as frequency, hesitancy, and urgency. However the ICD-10 guidelines instruct us to use additional codes for associated symptoms. R35.0 for frequency and R39.15 for urgency.

Since the frequency and urgency are symptoms of the BPH with LUTS we would consider this as two diseases and not four.
 
Thank you for replying. So for the medical decision making in this example it would be considered low.

Diagnoses= 2 points (limited)
Data= 2 points (limited)
Risk= moderate for 2 stable chronic illnesses
 
Thanks. I am going to expand this a little farther if that is ok :) For example the MDM is the same as above, and the HPI is comprehensive and the Exam is comprehensive. This is the way the doctor's dictate every time the patient is seen with the HPI and Exam. The patient comes in every six months/or every year. Would this be coded as a 99213 or a 99214? I know that its the 2 out of the 3 and since the HPI and Exam are met every time it could potentially be the 99214, but I have a hard time giving that every six months when the patient is stable. Am I making any sense? :)
 
KaylaRieken said:
Thanks. I am going to expand this a little farther if that is ok :) For example the MDM is the same as above, and the HPI is comprehensive and the Exam is comprehensive. This is the way the doctor's dictate every time the patient is seen with the HPI and Exam. The patient comes in every six months/or every year. Would this be coded as a 99213 or a 99214? I know that its the 2 out of the 3 and since the HPI and Exam are met every time it could potentially be the 99214, but I have a hard time giving that every six months when the patient is stable. Am I making any sense? :)
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I think your concern about the medical necessity of a comprehensive history and exam for a patient with basically two stable problems at a six month interval is a valid one. If the patient's symptoms and/or disease process are not worsening and the provider is not making changes to the care plan, I would have the same concern. While the comprehensive history could be justified since the provider may review the existing history and make any needed updates, I would discuss this with the provider and ask them if a comprehensive exam is really warranted in this situation, or if they are simply incidentally documenting additional systems in order to meet coding requirements to be able to bill a higher level. But ultimately, since this is a medical necessity question, it is the provider's call.
 
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