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Number of Dx for MDM

  1. Default Number of Dx for MDM
    Medical Coding Books
    I am needing some help regarding box A of the MDM portion of the 95 audit tool. I work for a specialty clinic and the dx codes that we use on a regular basis are normally very similar for every patient.

    My question is if I have lumbar disc degeneration, lumbago, lumbar radiculopathy and displacement of lumbar disc without myelopathy.....(and they are all stable) can I count 4 stable/improved established problems? Or would I group the similar codes together as one problem. I get really confused when the diagnoses are of the same body area and symptom.

    On the other hand, how would I count these same four dx codes if only one was worsening? For example, what if the what if the displacement of lumbar disc without myelopathy was worse and the others were stable?

    Any help/suggestions would be great!!!

  2. Default You can count them separately
    I would look to the report to see if each of the four diagnoses are being treated (with pain rx, physical therapy, etc.). Like a lot of MDM determinations, it can be a judgment call sometimes. Count each diagnosis that is addressed and/or treated during the encounter. Even if the codes are similar and of the same body area, you can count them separately for Medical Decision Making. It just depends on if the provider treats or addresses each of the conditions.

    If only one was worsening than you would credit 2 points for the worsening dx, and 1 point for the others that were addressed during the encounter. So if each of these diagnoses were addressed, the points would be:

    lumbar disc degeneration = 1 pt
    lumbago = 1 pt
    lumbar radiculopathy = 1 pt
    displacement of lumbar disc without myelopathy = 2 pts

    MDM Box A would be >4 or Extensive if one condition was worsening

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