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MDM Risk table STD check

  1. #1
    Default MDM Risk table STD check
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    Hi, I am looking only at the first column of the Risk table.... Low vs. Moderate. Would you consider (potential) exposure to STD low vs moderate.... I don't think there is a lot of stuff going on besides labs but I am hung up on the verbage "undiagnosed new problem with uncertain prognosis..." would you only consider this if the patient was experiencing symptoms? He is not showing symptoms--just is concerned because of exposure.

    Thanks
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  2. #2
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    I don't believe you have anything within column one of the table of risk based on the synopsis you present. In the absence of signs or symptoms, I don't believe the patient has a "presenting problem". Therefore I would focus on column two, and if labs were ordered, it would appear that your risk is minimal.

  3. Default
    If the patient came in with no symptoms, potential exposure, then this is an STD lab screening and I would give it a SF Risk

    If the patient came in with symptoms, potential exposure, then I would probably give it Low for acute uncomplicated illness (until proved otherwise)

    The "undiagnosed new problem with uncertain prognosis..." is more (example) a patient with a cough, office chest xray abnormal with an order for a CT. Basically this is for "I don't know what I am dealing with and don't know where we are headed till we do some more tests"

    I just wouldn't give it Mod risk for potential exposure. But it would really depend on the whole note.

  4. #4
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    Thank you. I wanted another opinion as the provider wanted a fairly high visit and I just couldn't see that it was supported. It helps to have more than one opinion when you need to "downcode" a provider
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

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