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MDM level

Vaida Posted Tue 30th of July, 2013 18:39:19 PM

What MDM level would be appropriate in this scenario: new patient comes for suspicious skin lesion, two diagnoses - 238.2 and 702.0 documented only, skin biopsy was performed for 238.2 and Cryosurgery for 702.0. Patient has no personal or family history of skin cancer. Can you please explain in detail how you came up with this MDM level using the MDM point system?

SuperCoder Answered Tue 30th of July, 2013 22:14:57 PM

New patient means that the problems are new to the provider. It is difficult to tell from your question but it seems like there were actually two lesions and they were treated differently. That would count as two new problems, one with additional workup (the biopsy), which leads to 4 points (or extensive) in the Number of Diagnoses or Treatment Options portion of MDM.

There doesn't seem to be any data reviewed (labs, x-rays, other provider documentation) so 0 points (or minimal) for Amount and/or Complexity of Data Reviewed.

In the Table of Risk, I would consider the presenting problem a new acute problem (low risk), skin biopsy is low risk in the diagnostic procedures column, and cryosurgery would be moderate risk in the management options column. You take the highest risk level, so risk is moderate.

When you combine extensive diagnoses, minimal data, and moderate risk, you get moderate complexity medical decision making.

I hope this helps.

Best,
Leesa

Leesa A. Israel, BA, CPC, CUC, CPPM, CMBS
Executive Editor, The Coding Institute
Manager, TCI Consulting & Revenue Cycle Solutions

Vaida Posted Wed 31st of July, 2013 12:56:58 PM

What a great answer. Thank you so much!

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