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I know I've asked this before, but...

  1. #1
    Question I know I've asked this before, but...
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    I'm in a funk of second-guessing myself, so I have to ask...

    If a patient is being seen to get a refill on a controlled substance (ie, Oxycodone), and everything is going smoothly, what would the MDM be?

    The diagnosis is back pain, which is well-controlled, and he didn't do any diagnostic procedures, because the problem is established. Thos most I can come up with is "Low" overall, but it seems like it should be at least moderate, based on the nature of the medication. Is that something that should be taken into consideration?

  2. #2
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    Quote Originally Posted by btadlock1 View Post
    The diagnosis is back pain, which is well-controlled, and he didn't do any diagnostic procedures, because the problem is established. Thos most I can come up with is "Low" overall, but it seems like it should be at least moderate, based on the nature of the medication. Is that something that should be taken into consideration?
    Based on the info you provided, if the back pain is well-controlled you would get 1 point for Established problem under Number of diagnosis ; If no data was reviewed, you would get 0 points for Data Reviewed; Under Risk you would have a Moderate level for Prescription drug management. Since you need to meet 2 out of 3 for the complexity, this would only add up to an MDM of straight forward!

    Does seem awfully low for the nature of the medication, but the doctor would have needed to do more in the other areas of the MDM to achieve a higher level!

    Thanks,
    Jodi Dibble, CPC

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