Wiki Urology Coding

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gherren

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Can anyone tell me in Urology is it rare to have a level 5 Consult? Most things we deal with in our clinic are kidney stones, uti's, prostate cancer , BPH, urinary incontinence, and impotence. (Inpatient consult or outpatient). The doctor most always has a high complex history, and exam but a more moderate medical decision making. I'm not sure If I am down coding on the moderate decision making. If the patient has other comorbidities that we are not treating but makes the patient higher risk. Would that up the medical decsion making to high even if we are not treating those comorbidities?
Thanks for any help
Ginger
 
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Mdm

The table of risk is just ONE element in determining the MDM level. (The others are problem points and data points.)

You do not have to be treating the comorbidities for them to count in terms of the table of risk. If your physician is recommending major elective surgery and the patient has identified risk factors (e.g. a pacemaker or diabetes) and the documentation clearly states those risk factors then you have a HIGH risk as per the table of risk. If you also have 4 or more data points -OR- 4 or more problem points then you get a extensive MDM. Remember, the physician must tell you that these conditions pose an additional risk to the surgery; you can't assume it's an additional risk just because it's listed in the history or ROS.

If you can post a scrubbed note, we can better help you determine what level of MDM you have.

Also, I'd recommend http://emuniversity.com/index.html. You can get a free subscription and it really helps to learn E/M coding. Each week there is a new "problem" to code and full explanations of the correct answer are given.

Hope I've helped.

F Tessa Bartels, CPC, CEMC
 
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