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E/M moderate risk?

  1. #1
    Default E/M moderate risk?
    Medical Coding Books
    Just wanted to get some opinions on this:

    If a patient comes in to the ER with a facial rash, for example, and the doc simply states the dx as facial rash, but underneath he documents that there are three differential dx's that it can also be. My question is, would you count that as a moderate risk because of the fact that it is an "undiagnosed new problem problem"?

    I'm thinking no but opinions differ in the office. Any words of wisdom?

  2. #2
    Salt Lake North
    Default Need to add up the other two components too
    To decide your overall MDM you need to look at all three components and add them up.

    Diagnosis/Management Options: 3 (Technically following the codes, but it is generous)
    Data: 1 (now doubt that he ran a lab. Very doubtful that he ordered X-rays or MRI too)
    Risk Table: Low

    Overall = Low

    On the risk table I would not put it as Moderate unless the documentation states the posibility of it being something like the "Flesh eating" or something like that. Most rashes are reactions and don't normally pose a great risk.

    My two cents worth

  3. #3
    It is an er visit, so the problem is new and the doc wrote a script for it, so all together, they add up, I was just curious about the differential dx part of the question.

    Thanks for your help!

  4. #4
    Milwaukee WI
    Default Wrote a script = moderate risk
    Prescription drug management is classified as moderate risk .... regardless of the problem. So if he wrote a script, then the RISK is moderate. You also have a new problem w/o workup = 3 points. So you get moderate MDM.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Thanks Tessa!

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