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SNF Medical Decision Making

  1. #1
    Default SNF Medical Decision Making
    Medical Coding Books
    I have a question about what is considered medical decision making of high complexity in 99306 (Inital Nursing Facility Care).

    The physician is admitting the patient from the hospital into a skilled nursing facility. He reviews "multiple medical records" from the patients hospital stay (including labs, test results, orders, etc. in addition to the patient's past medical records), so I believe that the "data" component meets extensive medical decision making. However I need another opinion on the other components of medical decision making (Diagnoses and Risk). Please consider the following two examples:

    1: Patient has severe senile dementia, chronic renal insufficiency, recent acute gastroenteritis and acute renal failure (resolved), poor oral caloric intake. Patient is on multiple medications for above.

    2: Patient is status post hip fracture (doing well), mild senile dementia, hypertension (stable), RAD (stable), GERD, chronic constipation, history of electrolyte abnormalities (stable), fall (uncertain as to reason, likely misstep). Again, patient is on multiple medications.

  2. #2
    Milwaukee WI
    Default Problem points
    Due to the number of existing problems with each of these scenarios ... even if you counted them as "Established problem; stable or improved" you would still get 4 problem points, because each patient has at least 4 things "wrong."

    4 problem points gets you to the high MDM when counted with your data points.

    F Tessa Bartels, CPC, CEMC

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