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Medical Decision Making - risk component

  1. Default My take
    Medical Coding Books
    Donna I like seeing your addendum at the bottom of every post...

    Anyway, I was always taught that the medical necessity sets the driving force behind the EXAM. If the pt is new, the physician still needs to get a full history especially if any rx are going to be given...CYA. That's makes a hx comp. I don't think you can do anything about the mdm, it is what it is. Obviously if the pt is new, it's a new problem to the provider, if an rx is given it's mod, if the pt has phary, oto, sinusitis, you're increasing your # of dx. You can't change that. To me the deciding factor is going to be the exam. However, again, when it's a new pt the doctor may feel it's necessary to perform a more extensive exam because they don't know them and if you have ever worked for a D.O. it's not uncommon for them to look for an underlying condition causing the illness. Is it medically necessary, sometimes but that's the doctor's call and they have to be able to defend it. Now, if I saw and eye exam on a broken toe I might question it's validity. But to make a blanket statement that a phary pt should be a 3 instead of 4 is a little quick.
    And that's my opinion.
    adrianne, cpc

  2. #22
    Default
    This is my final post on this matter - I'm tired of beating a dead horse.


    Acute otitis media
    - SELF LIMITED/MINOR PROBLEM
    http://en.wikipedia.org/wiki/Otitis_media

    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 – be sure to document these supporting elements. (Ingenix 2003, Coding for Evaluation and Management Services, page 9.)



    The End.

  3. #23
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    Quote Originally Posted by abenson View Post
    Donna I like seeing your addendum at the bottom of every post...

    Anyway, I was always taught that the medical necessity sets the driving force behind the EXAM. If the pt is new, the physician still needs to get a full history especially if any rx are going to be given...CYA. That's makes a hx comp. I don't think you can do anything about the mdm, it is what it is. Obviously if the pt is new, it's a new problem to the provider, if an rx is given it's mod, if the pt has phary, oto, sinusitis, you're increasing your # of dx. You can't change that. To me the deciding factor is going to be the exam. However, again, when it's a new pt the doctor may feel it's necessary to perform a more extensive exam because they don't know them and if you have ever worked for a D.O. it's not uncommon for them to look for an underlying condition causing the illness. Is it medically necessary, sometimes but that's the doctor's call and they have to be able to defend it. Now, if I saw and eye exam on a broken toe I might question it's validity. But to make a blanket statement that a phary pt should be a 3 instead of 4 is a little quick.
    And that's my opinion.
    lol...Adrianne - yeah, I had to put that in because a couple times when I posted "my opinion", it was misinterpreted as "gospel" or something - like what I said was written in stone somewhere! ... So, to prevent that from happening again - I put my little disclaimer in
    and I agree with your assessment of the posted matter, especially the part about a "the blanket statement". Very well stated!
    {that's my opinion on the posted matter}
    Donna, CPC, CPC-H

  4. #24
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    ARCPC9491 - see, now you're adding all sorts of "ifs and buts" and "excludes" and so on and so on.... and that is why when I post, I make it clear that it's my opinion on the "posted matter".... ei; your original post.... which is what we all responded to, and it's why we all kept trying to get you to see that just because it's pharyngitis or otitis, doesn't mean it's minor...ALL the documentation and issues MUST be taken into consideration to determine the level of service provided -HPI/EXAM & MDM - it's what we've been saying since first post. It's all in the documentation.

    I'm glad you see it now though.
    {still, my opinion on the original posted matter- not getting into the ifs, buts & excludes}
    Donna, CPC, CPC-H

  5. #25
    Location
    Woodland Hills, CA
    Posts
    121
    Default
    Dear ARCPC9491,

    People are just posting their opinions, based on their experience.
    Being the poster of the issue, you should respect our opinions.
    You can either agree or disagree, we don't have to know that.
    Last edited by HCCCoder; 08-15-2008 at 11:01 AM.
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  6. #26
    Location
    Greeley, Colorado
    Posts
    2,045
    Thumbs up
    Quote Originally Posted by lmartirosyan View Post
    Dear ARCPC9491,

    People are just posting their opinions, based on their experience.
    Being the poster of the issue, you should respect our opinions.
    You can either agree or disagree, we don't have to know that.
    True! These posts are just that - opinions and sharing our experience and how we were taught. Sometimes we even learn a thing or two! That's the beauty of it! The forum is not meant for arguments - simply discussion and sharing! I have learned A LOT from the forums and am extremely thankful that the Academy has provided this opportunity for us!
    Lisa Bledsoe, CPC, CPMA

  7. #27
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    I agree - I've learned a LOT on these forums. from others points of view and experiences!
    Donna, CPC, CPC-H

  8. #28
    Location
    Woodland Hills, CA
    Posts
    121
    Default
    Me too, I love this forum.
    Thaks a million, AAPC !!!!!!
    CPC CCS
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  9. Default
    I can't tell you how many times I have turned to you guys/girls for your opinions on how to code something or for a different perspective on sometime. Sometimes we need to look at things from outside the box, and I want to thank you all for your help and opinions.

    Oh and I am in the direct path of TS Fay...please say a prayer. We were completely destroyed by Charley 5 yrs ago.
    adrianne, cpc

  10. #30
    Location
    North Carolina
    Posts
    3,126
    Default
    I've been watching this one from the side lines and have been impressed with the passion in everyone's comments/opinions. I can certainly understand when someone feels that their "case" isn't being understood or possibly rejected,however; it is important to remember that we're a team. Once you begin to "burn bridges", it's very hard to repair them. There is always a place for constructive criticism but it must, also, be done with tact. I recently misunderstood someones comment on a post and another member of this forumn kindly pointed that out to me.

    "Teamwork is the ability to work toward a common vision"
    Last edited by RebeccaWoodward*; 08-18-2008 at 10:35 AM. Reason: spelling
    Rebecca CPC, CPMA, CEMC




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