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Medical Decison Making hELP needed

  1. #1
    Default Medical Decison Making hELP needed
    Medical Coding Books
    Consult hematology/oncology

    71 year old female with stroke symptoms

    working DX
    1. Anemia
    2. Stroke vs TIA
    3. DM
    4. CHF
    5. HTN
    1. Patient with chronic iron deficiency anemia. Patient has had an extensive workup as oupatient. Patient has also had a recent blood transfusion 1 week prior, thus iron panel will not be completely reflective. Will order iron studies, if low, than truly low and if normal may be secondary to recent transfusion
    2. Agree with MRI/MRA

    MDM Level ( Moderate or High)

    All help appreciated!!

  2. #2
    Unless there are other data points not mentioned I would go Moderate on this one.

    Laura, CPC, CPMA, CEMC

  3. #3
    Ellenville, New York
    Default agree with moderate
    Assuming MD has never seen pt before as this is a consult, I would give 4 pts for problems (all new, tests = W/U for anemia), 2 data points (lab, rad) and moderate risk, giving a moderate MDM level.


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

    2016 Secretary
    Ellenville, NY Local Chapter

  4. #4
    Thanks Ladies...Thats what I code but the doctor felt it should have been level 5...go figure

  5. #5
    Ellenville, New York
    Default Ladies???
    I resemble...oops resent that remark! Maybe I am living a sheletered life, but I never met a lady named "Lance"!


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

    2016 Secretary
    Ellenville, NY Local Chapter

  6. Default MDM is Physician Area of Expertise
    The RISK area of medical decision making is the area of physician expertise for which most coders know very little and are trained very little in.

    I would suggest a lengthy discussion with your physician(s) concerning this topic and go over case examples and vignettes from the CPT-4 Manual with high levels of MDM so that you both see eye to eye on this matter.

    I cannot fully comment on this to say that it is High MDM but if the Diagnoses/Management Treatment Options and Diagnostics Services areas have enough points for HIGH, then based upon the RISK outlined in your example I would tend to side with the physician in a case like this. Why? Because of the matters of differential diagnoses of Stroke versus TIA being conditions which would cause life, limb, and/or organ impairment or death. This may be why your physician considered the MDM high, due to the RISK associated with the disease processes involved and those being considered.

    Hope that helps at least for possibly future E/M assignment as well.

  7. #7
    Sorry Lance...It was just one of those days...Thanks for your help

  8. #8
    Maybe I'm missing something in the post but I don't see where it states anything about what the physician assigned the level of risk as.

    I am not clinical and I do not claim to be clinical but I am an auditor and I can level MDM based on the documentation presented to me. What I can not do is determine the medical necessity of it and I don't even try to.

    The physician treating this patient is a specialist in Hem/Onc and his MDM is focused on the anemia not the other issues.

    I also have to disagree with your statement that physicians are experts in MDM. Many physicians undervalue the level of MDM on a regular basis. Of course there are also those that overvalue as well. It is actually very scary how many providers have no clue how to quantify the level of service they have provided.

    Sorry to spout off like this but the equating MDM with medical necessity is something that really bothers me. Physicians are experts in medical necessity, unfortunately they often go above and beyond because todays sue happy world forces them to pratice defensive medicine. I can't make that determination though, I can just level based on the documentation.

    Laura, CPC, CPMA, CEMC

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