Hi everyone, Im having a little bit of an issue with a chart i am auditing for an OB/GYN. The patient is coming for her first OB visit for a complete physical (which would normally fall under Global), but the physician does not hear a fetal heart beat. she is only 7 1/2 weeks along, she states she is not having any symptoms other than those associated with being pregnant such as breast tenderness and fatigue. the physician put DX 640.03- threat to abort. In the plan the Physician orders labs and a cytopathology.
-(side note) the Dr. ordered a Suction D&C 6 days later.
My question is in the risk assesment portion of the MDM what would this classify as? Moderate or High? My colleague suggests "High" but I am on the fence, since the patient is not having any severe problems assoc. with the miscarriage.
Her history and exam were both comprehensive so the MDM is the decideron either a 99204 or 99205
Any help would be appreciated
Ivonne, CPMA
-(side note) the Dr. ordered a Suction D&C 6 days later.
My question is in the risk assesment portion of the MDM what would this classify as? Moderate or High? My colleague suggests "High" but I am on the fence, since the patient is not having any severe problems assoc. with the miscarriage.
Her history and exam were both comprehensive so the MDM is the decideron either a 99204 or 99205
Any help would be appreciated
Ivonne, CPMA
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