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What MDM and Risk?

  1. #1
    Overland Park, KS
    Question What MDM and Risk?
    Medical Coding Books
    A patient presents to the office with wrist pain. The final diagnosis from the provider is wrist pain.

    In the plan of care, no treatment was really given. The provider discussed the nature of the condtion with the patient and discussed the need to change work practices, get a split keyboard, learn to type correctly, etc.

    My question is under the MDM, what level of risk would you assign to this scenario? If all the provider does is talk about the patient changing his/her work practice, where does this fall under the risk since no treatment is being given?

    Also, would you score 3 points as a new problem w/o addional w/u, or since this is wrist pain and we are doing nothing more than discussing the need to change work practices, could this possibly be considered a self-limited or minor problem?

    I should mention here that this is a new patient. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  2. #2
    I would go with Low on the table of risk based on the presenting problem

    Acute uncomplicated illness or
    injury, eg, cystitis, allergic
    rhinitis, simple sprain

    And I would give 3 dx points since they advised the patient to change the way they are doing things I think it is safe to say this issue would not have resolved on its on and therefore doesn't qualify as self limited/minor and it is a new problem.

    Just my take on it,

    Laura, CPC, CPMA, CEMC

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