Hi everyone. I am needing some opinions on the diagnosis/treatment options of the MDM.
If a patient comes in for GI discomfort due to birth control pills and the physician changes it to another BCP, but no tests were ordered and the problem is not stated whether it is established or not I am having a hard time giving this physician a moderate decision making:
DX: 3
Risk: Mod
Complexity: 0
my main things is what is the difference between new prob. (no further workup) vs. limited or minor problem.
DX: 1
Risk: Mod
Complexity: 0
Giving this visit a straight forward MDM, which is more appropriate in my opinion.
This coupled with a EPF history, and no exam documented would give me a 99212 level vs. a 99213.
And if we are educating our physicians to document based on medical necessity then an MDM of 99214 seems rather high.
any opinions are welcomed.
Thank you,
Ivonne CPMA
If a patient comes in for GI discomfort due to birth control pills and the physician changes it to another BCP, but no tests were ordered and the problem is not stated whether it is established or not I am having a hard time giving this physician a moderate decision making:
DX: 3
Risk: Mod
Complexity: 0
my main things is what is the difference between new prob. (no further workup) vs. limited or minor problem.
DX: 1
Risk: Mod
Complexity: 0
Giving this visit a straight forward MDM, which is more appropriate in my opinion.
This coupled with a EPF history, and no exam documented would give me a 99212 level vs. a 99213.
And if we are educating our physicians to document based on medical necessity then an MDM of 99214 seems rather high.
any opinions are welcomed.
Thank you,
Ivonne CPMA
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