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MDM Coding for Hospitalist

  1. #1
    Default MDM Coding for Hospitalist
    Medical Coding Books
    I am having a difficult time determining how to code MDM for hospitalists. I have the H&P, Progress Notes, Discharge Summary that I am coding from.

    Number of DX or TRMT Opt: Do I document the dx codes that are listed on the assessment plan from the H&P or the Discharge Summary? Would we code most of them with a New Problem with a work up plan since most are being admitted or observation status?

    Amt of Data Reviewed: I have no problem here...

    Risk: Do we check off for every dx we have on the discharge summary for the presenting problem. and then check off all the work that was done throughout the entire hospital stay. If so would we review the Assessment, Progress Notes for this info?
    Last edited by lpyrtle; 08-01-2011 at 02:40 PM.

  2. #2
    Milwaukee WI
    Default Each document stands alone
    When it comes to MDM .... each document stands alone.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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