If a patient is being seen again for worsening abdominal pain and mild anemia and the physician sets the patient up for a colonscopy how do we count data points for MDM. For Data points,it is not a lab or xray and is not in the medicine section but in the surgery section. Also on the # of Diagnosis or treatment options portion of the MDM it is not a NEW problem with addtional workup, but a EST PROBLEM WORSENING. The risk should be moderate as is minor surgery w/risks, and undiagnosed problem with uncertain diagnosis.

Different scenario: Patient seen for a specific problem (knee pain & Dr. notices the patient should really have a colonoscopy due to age) or a physical and physician discusses with the patient about having a colonscopy and patient will then be set up for such and discusses the risks of procedure etc., do we put a diagnosis on the superbill for the reason for colonoscopy (screening, family hx). Currently we are not doing so I thinking it should be.

Please advise. Thanks in advance for the help.