This is my final post on this matter - I'm tired of beating a dead horse.
Acute otitis media - SELF LIMITED/MINOR PROBLEM
Acute otitis media (AOM) is most often purely viral and self-limited, as is its usual accompanying viral URI. There is congestion of the ears and perhaps mild discomfort and popping, but the symptoms resolve with the underlying URI.
This of course EXCLUDES bacterial acute otitis media - which normally is accompanied by a fever and is more complex. Which in this case, you get your "New problem and 3 points"
There are other types of OM - but the above 2 are most common.
Pick up a medical dictionary.
So, yes, I agree there are times where OM can be more than just a self limited problem - I never totally disagreed to that. However, half of the time, your classic OM case, is self limited/minor. I guess I didn't clearly state that "more often OM is SELF LIMITED"
To the comment about LABS and other data....of course this will "add" to the MDM....I am speaking specifically when there is NO data - because most of the time, there is none. However, on that note Donna, looking at the table of risk under "minimal" - labs fall under this category anyway.
So, you have your OM (self limited) labs, (1 point) and Rx (Mod Risk)- OVERALL MDM? MINIMAL/STRAIGHTFORWARD .......... you could even get LOW MDM if the patient had another self limited/minor problem. Just because LABS are ordered - doesn't change the "presenting problem" into something that it is not - it adds to the data component.
So, with the posts regarding... "Well you can use the HX and EX to get a higher level for established patients..." while the documentation MAY support that higher level... however, the MDM doesn't MATCH the LEVEL OF SERVICE - the HX and EX should support the MDM because the MDM is the driver for the HX and EX! Everyone is taught "the best/highest 2 out of 3" Not necessarily true!
My ending quote from Ingenix:
If the physicians can sense the level of service that the presenting problems require, they can then be certain to document the history and exam elements required to support the service. This is not to say that a code should be selected, then various amounts of history or exam performed to support it. Rather, the point is that if the level of decision making describes the real efforts in terms of identifying and managing a problem, and, as is almost always the case, especially with established patients, either the history or exam performed will support that level of decision making â€“ be sure to document these supporting elements. (Ingenix 2003, Coding for Evaluation and Management Services, page 9.)
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