Wiki Need Help EM Coding

[sauls]

what type of MDM are these two samples:

(Medicare pt, we follow Traiblazer in Virginia )
Using this CMS reference guide for EM coding:
http://www.trailblazerhealth.com/Publications/Job%20Aid/coding%20pocket%20reference.pdf

Case #1
DM type 2 stable, not optimized, obtain indices today, no med changes
HTN stable , obtain CMP/TSH today, no med changes
Hyperlipidemia: stable and obtain indices today, no med changes.

Continue current Medication, due for reinal exam, recommended Follow up: 3-4 mo.

Case#2
31 yr old , female
Initial visit.
Acute Frontal Sinusitis.
Ned Quick FLU,Prescribed: Azithromycin 250 mg and nasal spray.
Use Humidifier vicks for steam treatments. follow up 10 days if not better.

Thanks for your input.
Saul

 

[eJones317]

Case #1 = Moderate, Level 4
#dx= 3 stable, established problems
risk= Moderate, two or more stable chronic illnesses, prescription drug management

Case #2 = Moderate, Level 4

#dx= 3, New problem, no additional work-up planned
risk= Moderate, acute illness, prescription drug management

Hope this helps!
Erin

 

[sauls]

thanks for your response.

I agree with Moderate MDM on both however the Reference guide that we have for CMS is thru trailblazers and I am having a really hard time finding where:
A New Problem with no work up would fall under moderate.

the same for 3 stable chronics ( under number of Dx), from what I am understanding i get maximum of 2 points on this guide.


here is the link for the reference guide:
http://www.trailblazerhealth.com/Publications/Job Aid/coding pocket reference.pdf



http://www.trailblazerhealth.com/Publications/Job%20Aid/coding%20pocket%20reference.pdf