Wiki Number of Diagnoses in MDM

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renifejn

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How would you count this as a subsequent visit in the hospital:

Assessment: BPD, r/o sz, r/o sepsis, hydrocephalus

is this counted as 2 points or 4 points in the MDM?
 
Depends on the status of the problems. Really need more information to determine.

Laura, CPC, CEMC
 
The rule-outs are not diagnoses or problem (from the coding perspective) so I would not count them unless there is more detail, e.g., symptoms or signs listed. Otherwise, I agree with Laura. Are the problems stable, improving, getting worse? If no more info is available I would choose the lowest applicable: "stable".
 
Abnormal movement - ICD-9-CM 781.0 - would be another diag to count and the test is workup. Is this a new problem? Then you get 4 points for it. Are the BPD and hydrocephalus also actively managed? That's a requirement in order to count the diag.
 
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