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Level of MDM, New DX of A-fib

  1. #1
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    Cool Level of MDM, New DX of A-fib
    Medical Coding Books
    New patient comes in and is diagnosised with A-fib, which is a new DX for this patient. Doc orders blood thinners, no other testing or anything. I would say that this the Medical Decision Making for this visit would be "Moderate" due to Rx management. Still learning pathophysiology, is moderate accurate or could this be "High" from your experience? Thank you.

  2. #2
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    I agree with moderate MDM. The new diagnosis without workup gives 3 points in diag section, there is nothing in data, in the table of risk I would credit prescription drug management.
    The information you provided is very limited - if the patient has another issue that would also be addressed by your provider, or if you doc requests a consult from a specialist then there might be another point for diags.
    If your doc elaborates that s/he wants to have thorough checks while the patient is on blood thinners because they pose toxicity to this patient, then it might be high in the table of risk.
    In your case moderate is appropriate in my opinion.
    Karolina, CPC, CPMA, CEMC

  3. #3
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    From the limited information:
    You get 3 points for a new problem w/ no work up -- no data points -- moderate for rx drug management equaling overall MDM of moderate.

    Now let's just say the doctor were to order a cath or EP studies, you'd still have 3 points for the problem, now 1 point for data, and risk of high. However, you would still have a MDM of moderate. Now, normally people just don't have a-fib all by itself -- if there are other issues, your problem points would meet or exceed 4 -- if put in the scenario above, your MDM would be high.

    Does that help?

  4. #4
    Default Question to ARCPC9491
    Hi - just a quick question reg. your reply to this post:
    You expanded on the given scenario. In your version, why would you not consider the mentioned cath or EP study further workup? I would think if the doc orders a cath or an EP the A-fib would be a new problem with workup, thus giving 4 points in diag?
    Thanks for clarifying.
    Karolina, CPC, CPMA, CEMC

  5. #5
    Default
    Karolina: good catch, I mixed up 2 thoughts .... I was thinking "established" in the next visit (for further testing if necessary) let me clarify


    Correction:
    Now let's just say the doctor were to order a cath or EP studies, you'd have 4points for the problem w/ up, now 1 point for data, and risk of high. Your MDM is high.

    For FOLLOW UP of this issue:
    Now, normally people just don't have a-fib (a now established problem) all by itself -- if there are other issues, your problem points would meet or exceed 4 -- if put in the scenario above, your MDM would be high as well.

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