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  1. Default Mdm
    Medical Coding Books
    Need some feedback if this justiy for Moderate MDM for Dr. states order indicate "MRI rule out" his give higer credit per a pervious audit.

    CC: Left Groin pain, bilateral ankle pain

    GROIN PAIN (ICD-789.09)

    Pt will get me copy of ultrasound report
    Pelvic MRI, Sports Hernia Protocol, r/o sports hernia, osteitis pubis, adductor strain/tear
    X-ray B ankles
    Consider MRI of the ankles

  2. #2
    Default Mdm
    If these problems are new to this provider then you have 4 points for number of diagnosis or treatment options (New problem (to examiner); add'l workup planned (MRI) and then risk of complication and/or Morbidity or Mortality we have an undiagnosed new problem with uncertain prognosis It would be my opinion that this would meet a Moderate MDM.

  3. Default E/M Level
    Thank you for the detail appreciate
    Last edited by msingh23; 10-03-2014 at 07:36 AM.

  4. #4
    Default Add'l Workup
    I had a similar question and asked our consulting firm and was told the following:

    Recommend MRI implies the provider thinks there should be add'l workup and would count this, HOWEVER, if provider states "May consider MRI" it wouldn't be counted towards add'l workup.

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