The best thing to do is to google 1997 or 1995 E/M guidelines and audit tool. That will give you the worksheet for determining your MDM.
There are three components to MDM:
To arrive at the level of MDM you add your problem points
0-1 = minimal
2 = limited
3 = multiple
4 or more = extensive
Then add your data points:
(same scale as for problem points)
Then look at your Table of Risk
To get your overall level of MDM 2 of these areas must meet or exceed:
So if you have 3 problem points, 0 data points and moderate risk you have Moderate MDM.
So the auditor was correct ... in a VERY simplified fashion. If you have a NEW problem without any workup (e.g. patient presents with sinus infection) and you are prescribing medication (Rx for antibiotics given), you have 3 problem points and moderate risk which equals moderate MDM.
But what if your "new" problem is just a cold ... which would get better by itself without any intervention. Even if your physician writes a prescription for cough medicine (because Mom insists) you still only have 1 problem point and you will have straightforward MDM.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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