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MDM - Additional Work Up Planned

  1. Default MDM - Additional Work Up Planned
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    If a patient see the physician for the first time (new patient, new problem), and the physician schedules surgery for that patient next week. Under Table A, can you count 4 points for New Problem with Additional Work Up? Table A = the number of possible diangoses and/or the number of management options that must be considered. Wouldn't surgery be counted as a managment option? I am having a problem finding this scenario documented anywhere.

    The 95 guidelines for Number of Diagnoses or Management Options state:

    DG: The initiation of, or changes in, treatment should be documented. Treatement includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.

  2. Default
    A patient being scheduled for surgery I believe would describe the MDM or Table C (Table of Risk):

    Management options for a Low Level states - "-Minor surgery with no identified risk factors" ; Moderate Level states "Minor surgery with identified risk factors -Elective major surgery (open, percutaneous or endos and for a High Level states "Elective major surgery (open, percutaneous or endoscopic) with identified risk factors -Emergency major surgery (open, percutaneous or endoscopic)"

    It has always been my understanding an additional work-up reflected additional tests needed to confirm a disease process or identify a specific diagnosis, i.e. lab work, radiology, CT, etc.

    Hope this helps~
    Last edited by kukleja; 11-16-2010 at 06:53 PM. Reason: spelling

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