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Breast Pain- MDM

  1. Default Breast Pain- MDM
    Medical Coding Books
    In table of risk; would this be Minimal or Low?
    Dx Management; would this be Self Limited/Minor or New Problem, no addt'l wrk up

    During exam Dr found fibrous. Plan "reassure, disc chocolate, and caffeine as irritants, recheck after menstral cycle"


    Thank you

  2. #2
    Default
    I would consider this moderate, undiagnosed new problem with uncertain prognosis. Based on what you posted they have not diagnosed this yet.

    I would give new problem no work up 3 points for dx.

    Laura, CPC, CPMA, CEMC

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Low risk
    I'd be more inclined to categorize this as low risk.

    When I see "undiagnosed new problem with uncertain prognosis" I'm thinking there is more evidence to be gathered. In this case, the physician is not recommending any diagnositic procedures (ultrasound, mammogram, needle biopsy). Not recommending any Rx treatment. Physician seems certain this is minor, even if s/he wants to recheck after menstral cycle.

    I know, clear as mud ...

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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