Wiki Urinary Frequency MDM Problem Type?

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tori.a

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Patient presents for urinary frequency for years-- would this be considered a stable, chronic illness on the MDM table? Also has nocturia and occasional dysuria. Thanks!

Pt. presents for eval. of urinary frequency for years.
Nocturia x3. However, when she wears her CPAP, it goes down to 0-1.
Occas. dysuria
 
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The urinary frequency COULD be with exacerbation, progression or side effects of treatment, but that is not noted here. You do get chronic as it states "for years". I would consider that chronic stable.
The nocturia and dysuria are not noted whether chronic or acute. I will say in reality, it is likely chronic but if it's not noted, you must default to acute. They may even be self-limited or minor problems with the limited information provided.
For problem, I would consider problems as low based on only the information provided.
FYI - I would use this example as an education tool to my provider explaining if there was better documentation, it is likely the problems were actually moderate.
 
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csperoni said:
The urinary frequency COULD be with exacerbation, progression or side effects of treatment, but that is not noted here. You do get chronic as it states "for years". I would consider that chronic stable.
The nocturia and dysuria are not noted whether chronic or acute. I will say in reality, it is likely chronic but if it's not noted, you must default to acute. They may even be self-limited or minor problems with the limited information provided.
For problem, I would consider problems as low based on only the information provided.
FYI - I would use this example as an education tool to my provider explaining if there was better documentation, it is likely the problems were actually moderate.
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Thank you so much for the reply! That helps a lot. What about severe hydronephrosis with no known cause yet? Would this be considered an acute illness with systemic symptoms? I never see any urology based MDM guidance so I appreciate you.
 
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Severe hydronephrosis is likely moderate for acute illness with systemic symptoms.. The documentation must include what those systemic symptoms are in order to state they existed. If it just states "severe" hydronephrosis without elaboration, then again, I would use as an education tool for my provider. It always comes down to the documentation.
 
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