There has been a huge discussion in our office over table A.1 of the Trailblazer guideline.
The example is as follows:
Patient presents with a cut to the foot. Physician stitches the wound and documents that he is prescribing antibiotics although the wound is not currently infected due to risk of infection because the pt has DM. The physician also takes the patients chronic condition of hemophilia into account when rendering MDM and documents this.
Based on this, many in the office say they would assign 3 points for the number of diagnoses-
1 for the open wound under 'each new or established problem for which the dx and/or treatment plan is evident with or without diagnostic confirmation' and 2 points under '2 comorbidities clearly stated and supported by information in record.'
Others state they would only assign 2 points-
only counting these under the '2 comorbidities clearly stated and supported by information in record.' The reason for this argument is because it is believed that the open wound is figured in with the 2 comorbidities.
I've searched and searched for a guide to the Trailblazer guide (haha! Isn't that silly?!) and came up with nothing. Is there an E/M or Trailblazer whiz out there who can shed some light on this??
The example is as follows:
Patient presents with a cut to the foot. Physician stitches the wound and documents that he is prescribing antibiotics although the wound is not currently infected due to risk of infection because the pt has DM. The physician also takes the patients chronic condition of hemophilia into account when rendering MDM and documents this.
Based on this, many in the office say they would assign 3 points for the number of diagnoses-
1 for the open wound under 'each new or established problem for which the dx and/or treatment plan is evident with or without diagnostic confirmation' and 2 points under '2 comorbidities clearly stated and supported by information in record.'
Others state they would only assign 2 points-
only counting these under the '2 comorbidities clearly stated and supported by information in record.' The reason for this argument is because it is believed that the open wound is figured in with the 2 comorbidities.
I've searched and searched for a guide to the Trailblazer guide (haha! Isn't that silly?!) and came up with nothing. Is there an E/M or Trailblazer whiz out there who can shed some light on this??