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Thread: Question regarding MDM

  1. #1
    Join Date
    Apr 2007
    Harrisburg, PA

    Default Question regarding MDM

    AAPC: Back to School
    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
    Join Date
    Apr 2007


    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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