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Assessment and Plan MDM

  1. #1
    Default Assessment and Plan MDM
    Exam Training Packages
    I have a physician that states in his medical record......

    Assessment

    New Problems
    HIDRADENITIS SUPPURATIVA (ICD-705.83) --


    Prescriptions written today:
    DICLOXACILLIN SODIUM 500 MG CAPS (DICLOXACILLIN SODIUM) one po bid for 14 days. #28 x 0, 12/07/2009


    I need a second opinion, he only tells me he is giving the patient a prescription and nothing else Would you still bill this with Moderate MDM because he is writing a prescription.

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default MDM needs TWO components
    To arrive at the correct level of MDM you must meet (or exceed) at least TWO components:
    Problem points
    Data points
    Risk

    You have a new problem with no additional work-up = 3 points
    You have prescription drug management = moderate risk

    This adds up to Moderate MDM

    I am hoping you have a history and/or exam somewhere as well, in order to arrive at the correct E/M level.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default audit E&M
    Tessa,
    I have been looking at quite a few different E&M audit tools lately and I was just wondering which one that you prefer. I am finding that they all differ slightly and I am somewhat confused as to which one would suit me best. I just want to make sure that I am being consistent but I also want to code properly and be confident with the codes that I choose.
    And, Deb Mitchell, if you're out there, I would really like your opinion on this as well. Thanks ladies

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Which tool to use
    Leslie,

    Like many auditors I have accumulated various versions over the years. Most of them are similar but might just be organized on the page a bit differently. Generally they are based on the Marshfield tool.

    And, of course, it depends on whether they are geared for 1995 or 1997.

    I'm thinking that's not too helpful. But then again, nothing about E/M is an exact science.

    F Tessa Bartels, CPC, CEMC

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