Need Help EM Coding
what type of MDM are these two samples:
(Medicare pt, we follow Traiblazer in Virginia )
Using this CMS reference guide for EM coding:
DM type 2 stable, not optimized, obtain indices today, no med changes
HTN stable , obtain CMP/TSH today, no med changes
Hyperlipidemia: stable and obtain indices today, no med changes.
Continue current Medication, due for reinal exam, recommended Follow up: 3-4 mo.
31 yr old , female
Acute Frontal Sinusitis.
Ned Quick FLU,Prescribed: Azithromycin 250 mg and nasal spray.
Use Humidifier vicks for steam treatments. follow up 10 days if not better.
Thanks for your input.
Last edited by sauls; 02-24-2011 at 01:49 PM.
Case #1 = Moderate, Level 4
#dx= 3 stable, established problems
risk= Moderate, two or more stable chronic illnesses, prescription drug management
Case #2 = Moderate, Level 4
#dx= 3, New problem, no additional work-up planned
risk= Moderate, acute illness, prescription drug management
Hope this helps!
thanks for your response.
I agree with Moderate MDM on both however the Reference guide that we have for CMS is thru trailblazers and I am having a really hard time finding where:
A New Problem with no work up would fall under moderate.
the same for 3 stable chronics ( under number of Dx), from what I am understanding i get maximum of 2 points on this guide.
here is the link for the reference guide: