The expanded description in the Table of Risk (for determining MDM) states
"Decision not to resuscitate or to de-escalate care because of poor prognosis" (emphasis added by FTB)
To me, that means that the physician has to be actively involved in making the decision to employ a DNR order at THIS encounter to be given credit for High Risk based on this criterion. So if the DNR is already in existence and there's no discussion about continuing it, but is simply mentioned in the record as existing, I don't use this to assign high risk.
However, patients with an DNR in existence frequently have presenting problems that would also be rated "HIGH" in the table of risk.
Hope that helps.
F Tessa Bartels, CPC, CEMC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join