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Need Help EM Coding

  1. #1
    Cool Need Help EM Coding
    Medical Coding Books
    what type of MDM are these two samples:

    (Medicare pt, we follow Traiblazer in Virginia )
    Using this CMS reference guide for EM coding:

    Case #1
    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
    Initial visit.
    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.

  2. #2
    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!

  3. #3
    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:

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