For EACH problem determine if it is
- Self-limited or minor = 1 point per problem with a maximum of 2 problems per visit
- Established problem, stable or improved = 1 point per problem
- Establish problem, worsening = 2 points per problem
- New problem; no additional work-up = 3 points with maximum of 1 new problem counted per visit
- New problem; additional workup planned = 4 points
Table of Risk
My instructor taught me (and I still follow this).
Check first under Management Options Selected to see where your treatment plan falls. If it's HIGH you can stop here.
Next check the presenting problem grid to see where your problem(s) fall(s). If it's HIGH you can stop here.
Next check the Diagnostic Procedures Ordered grid to see if your plan includes any of these items.
FINALLY - pick the HIGHEST single box.
For the scenario you gave us it would fall in Moderate Risk because of 2 or more stable chronic illnesses; you would get 2 problem points (1 point for each established stable illness); you would get 3 data points (1 point each for ordering labs, Xray, EKG) for a total MDM of Moderate.
Hope that helps
F Tessa Bartels, CPC, CEMC
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