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Treatment options in the MDM

  1. #1
    Question Treatment options in the MDM
    Medical Coding Books
    Hi everyone. I am needing some opinions on the diagnosis/treatment options of the MDM.

    If a patient comes in for GI discomfort due to birth control pills and the physician changes it to another BCP, but no tests were ordered and the problem is not stated whether it is established or not I am having a hard time giving this physician a moderate decision making:

    DX: 3
    Risk: Mod
    Complexity: 0

    my main things is what is the difference between new prob. (no further workup) vs. limited or minor problem.

    DX: 1
    Risk: Mod
    Complexity: 0

    Giving this visit a straight forward MDM, which is more appropriate in my opinion.

    This coupled with a EPF history, and no exam documented would give me a 99212 level vs. a 99213.

    And if we are educating our physicians to document based on medical necessity then an MDM of 99214 seems rather high.

    any opinions are welcomed.

    Thank you,
    Ivonne CPMA
    Last edited by Ivonne C.; 07-08-2011 at 08:40 AM.

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Minor Self-limited Problem
    A minor, self-limited probelm will go away without any treatment.

    If the patient is having a reaction to medication, this will NOT go away without treatment (even if the only treatment is discontinuing the medication causing the side effect). So this is a new problem (unless the patient has complained of this side effect with this medication previously) with no additional workup. And your risk is moderate because of Rx management (new script).

    So you have moderate decision making.

    With an EPF history the highest level of visit you can have is 99213 in any case.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default
    thank you Tessa,

    the only thing that was confusing was the difference between the two. with the audit tool that namas gave it didnt specify whether the self-limited or minor problem was for an established or new patient..

    Lets say that the history was detailed, would you as an auditor feel comfortable giving this visit a 99214 level?

    Sorry, i have been doing this for a little bit and sometimes the border line coding can be confusing.

    Thank you,
    Ivonne CPMA

  4. #4
    Default
    Quote Originally Posted by Ivonne C. View Post
    Hi everyone. I am needing some opinions on the diagnosis/treatment options of the MDM.

    If a patient comes in for GI discomfort due to birth control pills and the physician changes it to another BCP, but no tests were ordered and the problem is not stated whether it is established or not I am having a hard time giving this physician a moderate decision making:

    DX: 3
    Risk: Mod
    Complexity: 0

    my main things is what is the difference between new prob. (no further workup) vs. limited or minor problem.

    DX: 1
    Risk: Mod
    Complexity: 0

    Giving this visit a straight forward MDM, which is more appropriate in my opinion.

    This coupled with a EPF history, and no exam documented would give me a 99212 level vs. a 99213.

    And if we are educating our physicians to document based on medical necessity then an MDM of 99214 seems rather high.

    any opinions are welcomed.

    Thank you,
    Ivonne CPMA

    I know that fine line can make you really second guess yourself and can really get you confused....I've totally been there.
    I would code that visit as a 99213. The History was EPF and no exam, so even if you do have a moderate MDM, you aren't going to meet the 2/3 components to bill a 99214.

    Hope that helps!

  5. #5
    Default New problem
    For a new problem planned work up/or no planned work up "New Problem" is determined by is the condition new to the provider. See CMS audit tool they clarify "new to provider"


    Hope this helps,
    WSRCPC

  6. Default
    Hi,
    I agree with 99213..
    Reason for the visit is reaction to medication,With an EPF history.No Exam and work ups done..Need to bill 99213.

    Nalini CPC

  7. #7
    Default
    Hi Ivonne,

    Self limited / minor problem can be a condition that might not require any treatment, that would resolve with time without treatment, with rest for example.
    New problem (with no work-up) can be a condition that needs treatment or prescription.

    Now with the scenario you have mentioned, GI discomfort = new prob (NDMO-3), ACOD-none (no work up), Risk-moderate(since prescription is managed) but above all the nature of the presenting problem seems to be low to moderate.
    With EPF History, no exam, moderate MDM, I would suggest 99213. (Even if history is detailed )

    Hope this helps!
    Shirley K.C, BPT, CPC - H
    Have a nice day!

  8. #8
    Default
    Thank you for your Help. Seeing the same scenerios all the time, it does make me question myself from time to time, so I do appreciate it.

    Ivonne CPC, CPMA

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