medical decision making

Can someone help with the following. I was asked to consult on a patient with a possible infected peritoneal dialysis catheter. I saw the patient, reviewed labs (1 point), and determined that the patient would have to go to the OR for a "relatively minor" operation to remove the catheter...(I was unable to do it at bedside). What is the level of medical decision making? Is this a minor problem or new problem no workup planned? 1 point for reviewing labs. And how would you clasify the risk?

Medical Decision Making

For number of diagnoses/treatment options: new problem, three points
Data, lab, one problem
From the table of risk: minor surgery with identified risk factors, three points (moderate)

Overall MDM: moderate

A patient with an infected peritoneal catheter must have underlying medical problems and so I'll classify that as a patient with risk factors.

medical decision making

Thanks. I would have undercoded that. The patient in fact has a catheter in for removal of malignant ascites because of metastatic uterine cancer. She is frail and had bacteremia. Why would this be a new problem rather than minor problem...(what exactly is a minor problem?)

Mdm

The guidelines give these examples: cold, insect bite, and tinea corporis. But, frankly, most auditors count colds and insect bites as new problems. (A patient who presents with an insect bite usually has concerns about a tick.) I count minor problems, in addition to existing problems when auditing, but rarely use minor problem in the number of diagnoses/treatment options for a newly presenting problem. And, for a hospitalized patient with an infected catheter, I don't think the most conservative of auditors would say minor.