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Question regarding MDM

  1. #1
    Harrisburg, PA
    Default Question regarding MDM
    Medical Coding Books
    Patient is being seen for acute sinusitis. Physician is billing a 99214. He has an expanded problem focused history, detailed exam and moderate complexity for his medical decision making. When auditing this I gave a "3" under number of diagnoses because this was a new problem to the doctor and under amount and/or complexity of data reviewed it came out to a "0" since nothing was ordered. Risk of complications came out to a moderate due to the fact patient was given a rx for an antibodic. Is this correct? This seems to be a high level for just sinusitis.

  2. #2
    This is correct. You have to consider that anytime they give an Rx they are putting themselves at risk, whether the reason seems simple or not.

    Laura, CPC, CEMC

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