Results 1 to 6 of 6

Medical Nesessity

  1. #1
    Default Medical Nesessity
    Medical Coding Books
    HI All

    What are your thoughts - is giving a prescription drug a prescription drug management? What do you think drives the medical decision making - a presenting problem or giving a prescription adjustment? What are your thoughts when a physician examines 9 body parts for a simple sinusitis?

    Thanks!

  2. Default
    Yes,

    Giving an rx is rx management. What drives medical decision is documentation. MDM is not limited to just the rx management or presenting problem. It's a combination of the number of diagnosis/treatment options, data complexity and risk.

    If you just go off of the current documentation from your question, you have prescription management (moderate) sinusitis (minimal because it's a self-limited problem) and no documentation of data review/given. If I assume this is a new problem with no workup planned I would give this medical decision making a low.

    Does that make sense? Of course it depends on if this is chronic or acute.
    Christopher J. Halk, CPC
    Kunsan Air Force Base
    Republic of Korea

  3. #3
    Location
    New Windsor, New York
    Posts
    1,183
    Default Thoughts on your second question
    Quote Originally Posted by oreyeszwirn View Post
    HI All

    What are your thoughts - is giving a prescription drug a prescription drug management? What do you think drives the medical decision making - a presenting problem or giving a prescription adjustment? What are your thoughts when a physician examines 9 body parts for a simple sinusitis?

    Thanks!
    If that is the chief complaint and first listed diagnosis, and the ONLY diagnosis, then there could be questioning of the medical necessity of why a comprehensive exam was done. Also, keep in mind exam is only one part of the equation. If there isn't a lot of history documented (ROS is only minimal, for example) then it wouldn't matter. From Chris' analysis, you have low MDM - so if there is EPF history, it still would be 99213 despite the comprehensive exam.

    Also, if there are also chronic conditions being monitored, then a comprehensive exam may be in order and perfectly reasonable.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

  4. #4
    Location
    Daytona Beach, FL
    Posts
    752
    Default
    Quote Originally Posted by cjhalk@yahoo.com View Post
    Yes,

    Giving an rx is rx management. What drives medical decision is documentation. MDM is not limited to just the rx management or presenting problem. It's a combination of the number of diagnosis/treatment options, data complexity and risk.

    If you just go off of the current documentation from your question, you have prescription management (moderate) sinusitis (minimal because it's a self-limited problem) and no documentation of data review/given. If I assume this is a new problem with no workup planned I would give this medical decision making a low.

    Does that make sense? Of course it depends on if this is chronic or acute.
    If that is the chief complaint and first listed diagnosis, and the ONLY diagnosis, then there could be questioning of the medical necessity of why a comprehensive exam was done. Also, keep in mind exam is only one part of the equation. If there isn't a lot of history documented (ROS is only minimal, for example) then it wouldn't matter. From Chris' analysis, you have low MDM - so if there is EPF history, it still would be 99213 despite the comprehensive exam.
    RX management is only one part of the MDM, so it would not be the driving factor - only part of the equation. The presenting problem is the medical necessity - so that would be what should determine the need for the level of exam. For sinusitis, I would think that 9 systems would be over documentation depending on what was examined. However for sinusitis the exam would probably be at least a detailed exam. If this is a new problem, with no data reviewed and moderate risk for the RX of prescriptions, the MDM would be moderate. This alone for an established patient would give you a 99214. An Expanded problem focused history would not change the level, unless this was a new patient!
    Jodi Dibble, CPC

  5. #5
    Default
    I agree with Jodi on this one.

    I'm curious how a self limited or minor problem (1 point), no data points, and moderate risk is being leveled out to Low. If you consider sinusitis self limited or minor, which I personally disagree with if the provider is writing a script for it, that would limit you to Straight Forward. You need 2 diagnosis or data points to get to Low.

    Laura, CPC, CPMA, CPC-I, CEMC

  6. #6
    Location
    New Windsor, New York
    Posts
    1,183
    Default
    Quote Originally Posted by LLovett View Post
    I agree with Jodi on this one.

    I'm curious how a self limited or minor problem (1 point), no data points, and moderate risk is being leveled out to Low. If you consider sinusitis self limited or minor, which I personally disagree with if the provider is writing a script for it, that would limit you to Straight Forward. You need 2 diagnosis or data points to get to Low.

    Laura, CPC, CPMA, CPC-I, CEMC
    That is how I got to low - I didn't consider sinisitis a "minor" problem, so it's either established and worsening to make the patient present or it's new to the provider. Either way - works out to low. Not saying Jodi is wrong, not saying I am wrong - it's just how the coder/auditor would interpret this. Of course the complete note and record would help.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

Similar Threads

  1. Replies: 0
    Last Post: 01-14-2011, 02:09 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.