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MDM question

  1. Default MDM question
    Medical Coding Books
    How would you credit medical decision when the plan is to refer the patient to a specialist? this is a new problem and the only plan is to refer the patient to a specialist.

    Denise Smith

  2. #2
    The first column in the table of risk is for presenting problem.

    Is it an undiagnosed new problem? That would give you moderate. Just look thru that category and see where you fall.

    Laura, CPC, CPMA, CEMC

  3. Default
    The provider did a detailed history and a detailed exam. The assessment and plan was written as flat feet/ podiatry referral.

    Thank You
    Denise Smith

  4. #4
    If this is an established patient you would have a 99214 based on history and exam.

    For MDM, I would go with low on this based on one stable chronic.

    I supposed it could go moderate if you can show mild exacerbation, progression, or side effects.

    Laura, CPC, CPMA, CEMC

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