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Post chart audit,RE: Diagnosis for MDM

  1. Question Post chart audit,RE: Diagnosis for MDM
    Medical Coding Books
    Hi - I am currently auditing chart notes(post-audit) for a Cardiology office, would all of these be counted as a diagnosis for MDM summary?
    1.) Chest discomfort
    2.) Family history of coronary disease, in particular her mother.
    3.) Blood pressures elevated at home recently.
    4.) Recent herniated disk.
    5.) Known history of aortic regurgitation, noted as trivial in echo in 2007.
    (this chart note by an MSN,FNP,APRN,BC with physician sign off)

    (the Subjective note basically stated pt. has been having hypertension episodes/chest discomfort.)
    Recommendations were Myoview Nuclear stress test and Echo ordered, continue current meds, Follow-up after tests completed.)
    Thanks for any/all help with this.

  2. #2
    2,4,5 is just extra information to support risk factors (my opinion)

    1 is new problem with work up ... so you have 4 points and that's the highest you can get anyway

    then we have a point for a radiology test and a medicine test ..2 points

    Risk is high, cardiovascular imaging w/ risk factors.

    Overall your MDM is of high

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