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Help with medical decision making

  1. #1
    Location
    Modesto, CA; Central Valley Chapter
    Posts
    225
    Default Help with medical decision making
    Medical Coding Books
    Hi, Please help!

    Patient presenting with bilateral hip pain that has reocurred. Provider states dx as osteoarthritis and trochantric bursitis.

    Does this count as a minor/limited problem, established problem worse, or 2 self limited or minor problems.

    Provider reviews xrays. 1 point for data reviewed.

    Patient was advised regarding possible future surgery. Advised to contact PCP to be managed with analgesics and consideration of anti-inflammatory medication.

    Under management options is this zero since he is sending the patient back to the PCP for management?

  2. #2
    Default
    Quote Originally Posted by codingangel View Post
    Hi, Please help!

    Patient presenting with bilateral hip pain that has reocurred. Provider states dx as osteoarthritis and trochantric bursitis.

    Does this count as a minor/limited problem, established problem worse, or 2 self limited or minor problems.

    Provider reviews xrays. 1 point for data reviewed.

    Patient was advised regarding possible future surgery. Advised to contact PCP to be managed with analgesics and consideration of anti-inflammatory medication.

    Under management options is this zero since he is sending the patient back to the PCP for management?

    A question before I answer

    #1. Is this the first time this provider has seen this pt


    From the way you stated it seems to me like the doc is sending pt back to pcp for management.

    If this is the case, it would be new problem to examiner, no additional work-up would be 3 points.

    If this is not the first time this provider has seen the pt, then since it's a recurring problem I'd give it established problem worsening...

    Let us know

    Roxanne Thames, CPC

  3. #3
    Location
    Modesto, CA; Central Valley Chapter
    Posts
    225
    Default
    The patient is established.....

    thanks a bunch for your input.

    Tina

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