Q&A Medical Decision Making Points ( E & M )

[Thomas Koshy]

Can someone explain me the following :-
'' In MDM - Making Points : New Problem No work up planned ( maximum of 1 ) ''

Does this mean that an encounter can have only ONE New Problem ?
What if the patient has more than one New Problem ? Which one to select in these ( New Problems )
Thank you .

 

[Alicia Scott]

In some way that is what this means Thomas. Look at it this way. If a patient has DM and is coming in for a 6 month follow up but the doc checks his feet and notices an ulcer that is an added problem. Then the patient stated that they are having trouble with their ears and hearing. His ears are checked and both are full of cerumen (wax) so the doc cleans out the ears via irrigation. The doc looks at the patients vitals and the past three visits notices that the pt. has an increasing blood pressure. He instructs the pt. to get a digital blood pressure unit and have him record his BP then come back in a week to check on the ulcer and BP.

With all this going on you can only increase the MDM by one. If it is an established patient you have only to have 2 of three to increase that level.

 

[Ruth Sheets]

Laureen answered your question ,Thomas, in the July 2013 Q&A Webinar. I can't begin to do it justice, but it is available in the CCO Club. Also, this blog post may be helpful: https://www.cco.us/em-medical-decision-making/