• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Number of Management Options

Create Wiki
W

wynonna

True Blue
Messages
539
Location
Hinsdale, MA
Best answers
0
A provider documents 3 diagnoses under Assessment.
Her exams are always level 4 with at least 6 body/organ systems for detailed level 4 exam. History sections vary.
Would visits with level 4 detailed exams and 3 diagnoses under Amount/complexity of data be all level 4? with key factor being at least 3 dx listed in assessment? Assuming table of risk is moderate/level 4 (Prescription drug Management) also assuming 1 or less points under Amount and complexity of data (low or minimal)
thanks
 
Management of 3 or more problems or chronic conditions involving prescription drugs generally would qualify as moderate MDM. So for an established patient visit with a detailed exam, yes, these would qualify as level 4 visits. I would add though that, in my experience, many auditors look for more than just having 3 diagnosis codes listed. The documentation should also reflect that all three problems were assessed and treated or influenced treatment decision at that encounter in order to warrant being counted toward the complexity of the MDM, and that the level of history and exam are appropriate to the presenting problems.
 
You must log in or register to reply here.
Top