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Thread: Medical Decision Making

  1. #1

    Default Medical Decision Making

    AAPC: Back to School
    When a patient comes in with a dx of a URI, would this be considered a self limited problem or a new problem with no additional work up planned in the Diagnosis or Management Options section?

    We have been having alot of URI's and sometimes this could be the decision maker between a 99213 and a 99214. I know when they use the Dx as a cold and give no prescriptions, it would be a self limited problem. But if they dx the symptoms as a URI and give a prescription, would this be a new problem, no additinal workup planned?

  2. #2
    Join Date
    Apr 2007
    Kansas City, MO


    I have this same issue. A URI can be as straightforward as a cold...but can also turn into a bacterial infection and need a rx. I've decided to take this on a case by case basis. Like you mentioned, if the doctor felt they needed a rx, I give them a moderate MDM, and if not, consider it low MDM. I wish I felt more confident with these. I try to tell my docs to be more specific than "URI"...if not with another dx, than atleast with more details on the "status" of the disease.
    Just my two cents...maybe someone else can give us something more concrete.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  3. #3
    Join Date
    Apr 2007


    Looking at the MDM auditing tool; because of the Prescription drug management (script given) that is a (Moderate risk) I would say 99214 as long as the other elements support you level? just my opinion!

  4. #4


    I agree, Dr's need to be a little more specific with URI's. With the auditing tool a RX automatically makes the MDM moderate complexity but I was taught that if the HPI/ROS and Exam is not detailed then it's not a 99214. You probably can get away with a 99213 just to be on the safe side of not over coding. Often times I refer back to previous visits just to see if its a new problem. I maybe wrong on this matter, corrections are greatly appreciated.

  5. #5


    An RX does not automatically make the MDM moderate complexity, it only makes the risk moderate. You have to consider the other parameters as well (i.e. number of dx, amount and complexity of data to review). As for a URI, I look at this from the presenting problem standpoint. I say if a script is issued, then I agree it is moderate risk, if not, I would assign a low risk for an acute uncomplicated illness.

    Just my two cents for whatever it is worth!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  6. #6


    A lot of symptoms can be lumped into the diagnosis "URI". I usually look at all the symptoms documented as well as the rest of the HPI, ROS, Exam and MDM. If the patient has some upper airway congestion and the doctor sends them home and recommends keeping hydrated, use a humidifer, and tylenol or motrin for discomfort, I definately do not give a level 4 visit. Even if the doctor sends the patient home with some prescriptions for medicines that could be considered OTC meds I still don't give a level 4 unless there are multiple syptoms that may be pointing toward something more systemic.
    Just my .02 worth.

  7. #7
    Join Date
    Apr 2007
    Williamsport, PA


    Your initial question was regarding the presenting problem. Unless the patient was in for the same problem previously, or comes into the office frequently for every minor problem, I think this would be a new problem with no additional work-up (unless a throat culture is done.) The physician will have to distinguish between a problem involving ears, sinuses, throat and lungs; bacterial vs viral. In my opinion, a minor problem doesn't require much to determine course of treatment (infected splinter, severe sunburn,thrush, etc.)

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