Table of Risk

[wynonna]

Assuming my provider documents a level 5 comprehensive exam.
If patient was diagnosed 3 weeks ago and hospitalized for urosepsis, is the MDM high risk? Overall level 5 for established pt?
Thank you

 

[Pathos]

So the Medical Decision Making is comprised of three components, two of the following three components will determine the Complexity:

• Diagnosis and/or Management Options
• Amount and/or Complexity of Data
• Overall Risk

Now depending on how documentation described the urosepsis, along with any other documentation that could be used towards the MDM (Dx/Mx, Data, Risk).

Unfortunately, you are not providing enough information to make an informed call on the MDM for this patient; also I am a bit unclear on what you are asking, apart from needing to know the MDM level. I do not have enough information to determine if the patient is an Established patient, based on your post.

If the patient is considered an Established patient (within 3 years), and the physical exam is sufficiently documented to be comprehensive; I would need to know what else is the provider doing for the patient:

• Is the urosepsis New to the Provider?,- any additional workup? - or is the problem Established to the Provider and stable/worsening?
• Is the provider reviewing/ordering any data (labs/radio/medical studies/records/etc.)
• How "bad" is the urosepsis currently? - ordering any diagnostic studies? - what are the management options (Rx, IV, surgery, etc.)

Knowing the above information should guide you in determining the E/M level.

Source:
CMS E/M guidelines

 

[thomas7331]

I agree with the post above - a diagnosis alone is not sufficient to be able to assign a level of risk or MDM, or to be able to determine the level of an E&M code. It's also important to remember, per the official E&M guidelines that "because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one." So a diagnosis by itself does not represent a particular level of risk - rather it must be understood in the context of the encounter that is documented.

I'd just add too that 'urosepsis' is also not a meaningful and there is no way from this to understand what the patient's true condition is (or to even know what diagnosis code to assign). Per the ICD-10 official guidelines: "The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification."

 

[wynonna]

Under Table of Risk, HIGH risk, are examples such as: multiple trauma, acute MI, pulmonary embolus, severe respiratory disease, severe rheumatoid arthritis, acute renal failure, peritonitis, seizure, TIA weakness, sensory loss. (they are under Present Problem, High Risk, on bottom left of Table of Risk.) Sepsis is a common cause of death and is a systemic inflammatory response to infection. Urosepsis may have begun as a urinary tract infection and spread systemically. Normally when we are the first provider to see a patient after such a serious event that landed our patient in the hospital, I view it as high risk, and verify it as a 99215 assuming Exam is comprehensive, and note has also scored High risk under Number of Diagnoses/Management Options.
Thank you for your input