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Flat feet MDM

  1. #1
    Location
    Rose City (Portland, Oregon)
    Posts
    321
    Default Flat feet MDM
    Medical Coding Books
    There are 5 of us that have coded the following 2 scenarios and we can't agree on the level of MDM. Please help!!!!

    Scenario #1: A child has flat feet for which the note states she has no pain and no difficulties with any activity. The MD states this problem should resolve itself in 2-3 years and, if she develops pain, she may come back for orthotics. follow-up prn.

    Scenario #2: Same as above except the patient also is knock-kneed. No pain, no difficulties. Same A&P.

    What is the level of medical decision making in each case (SF, low, mod)?

    Thanks much!!!

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Self-limited problem
    Scenario #1: A child has flat feet for which the note states she has no pain and no difficulties with any activity. The MD states this problem should resolve itself in 2-3 years and, if she develops pain, she may come back for orthotics. follow-up prn.
    Self limited problem 1 point / NO data pts / Minimal risk = SF MDM

    Scenario #2: Same as above except the patient also is knock-kneed. No pain, no difficulties. Same A&P.Self limited problem x 2 = 2 points / NO data pts / Low risk = LOW MDM

    F Tessa Bartels, CPC, CEMC

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