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  1. #1
    Default Mdm
    Medical Coding Books

    help me getting mdm for the following condition: problem with additional work up
    2.lab.inves.-2+1ultrasound+physician performed the u/s and gave report.
    3.prescribed antibiotic

    diagnosis: vaginitis


  2. #2
    # of Dx or Management:
    New Problem with additional work up would count 4 points.

    Review and/or order labs: 1 points
    Independent visualization of US 2 points
    Total 3 points

    Level of Risk:
    Moderate (prescription management)

    OVERALL: MDM is Moderate

    Hope this helps.

  3. #3
    If you are billing for the professional component of the US, you may not count the independent visualization of the US in the Amt/Complexity of Data Reviewed. In this particular scenario, the MDM wouldn't change if only 2 total points were given for the review/order labs and review/order radiology tests.


    If the provider is billing separately for the interpretation of a test in the radiology and/or medicine section of the CPT, then that same physician should not take credit for the independent visualization of that test in the Amount and /or Complexity of Data Reviewed Section of the Medical Decision Making key component of an E/M.

  4. #4

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