Wiki Sore Throat MDM

[JuliaGiddens]

Hello friends, I am having a struggle with the MDM on a sore throat, and I am seeing this increasingly on documentation, and even my providers are divided on this subject. A patient comes in, diagnosed with sore throat, are basically told it will run its course, rest and salt water gargles are recommended. However, my providers routinely give out tetracaine suckers to help with the sore throat pain. I feel that despite the fact that the suckers are given, which I guess could technically be considered "prescription management" on the table of risk, I am thinking that on the management options, this would be considered a self-limited problem, as the sore throat would resolve itself without the suckers, and they aren't used to cure the sore throat. Also, its the same stuff that you can get from the pharmacy that you can spray in your throat, just in the form of a sucker. Half of my providers think this should be a "new problem, no additional work up planned" and the other half think this should be "self-limited or minor."

 

[thomas7331]

I would consider this scenario, generally speaking, to be low MDM. I would definitely not count the risk as 'moderate' for this kind of problem - even if there is a prescription I think 'low' risk is more appropriate for a sore throat in an otherwise healthy patient. So overall MDM would come to either SF to low depending, as you mention, on whether you count the problem as self-limited or new. Providers I have discussed this with lean toward it being a 'new' because it can be symptomatic of a systemic illness, but I find that this doesn't usually impact the code level because typically a sore throat will warrant more detail in the history and exam than other minor problems and this will usually bring the visit level to a 99213 anyway. Of course, each encounter's documentation has to be evaluated on its own merits as always.