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Wiki Rash due to Allergic Reaction to Medication - Leveling

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drummrgirl108

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Hi, I came across a charge where patient presents with a Rash for 1 week. Patient has been on Sertraline for 4 weeks and suspects rash is an allergic reaction to the sertraline. Doctor stops Sertraline and prescribes Prednisone.

Would you count the problem portion of the MDM table to be moderate in this case?
I know a rash is typically Low MDM (Acute Illness), but since it is an allergic reaction, does that mean it would be a higher level?
 
In my opinion, the patient is being treated for a chronic illness (anxiety or depression with Zoloft) and the patient had a side effect of the treating medication (rash from Zoloft). This would meet the criteria for 1 chronic illness with exacerbation, progression, or side effects of treatment.
 
Thank you for your response. I too am leaning more towards Moderate complexity.
Just a question: Doctor did not document any anxiety in the chart for this visit. Although Sertraline is used for anxiety/depression, can I as the coder assume Chronic Illness with Exacerbation then without documentation of anxiety?
 
I definitely think there should be thorough documentation of the anxiety/depression disease. Is it stable vs unstable? Never assume...If it's not documented it wasn't done mentality.
 
Got it! Thank you! Doctor did not mention anxiety and did not mention if it was stable or not. Would rash due to allergic reaction to Sertraline which led to a stop in sertraline and a new order of Prednisone support Moderate MDM without the discussion of patient's anxiety? No data to go off of on the MDM table. All that was mentioned is Sertraline started 4 weeks prior to this visit.

Because the rash led to prescription management, would that make it more complex than an Acute Illness?
 
I do not think so unless the MD documented concern or a reasoning for the "higher morbidity" in the patient. It sounds like it would just meet an acute uncomplicated illness.
 
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