Forum - Questions & Answers

May 9th, 2012 - karik

struggling with MDM

Here is my example:

Pt comes into urgent care with CC as sore throat.
HPI is sore thoart X 1 day with dysphagia. No fever, no cough. No sick contact.

ROS: Cons- neg fever, neg sweats, ENT-pos sore throat, neg colds, Resp-neg cough

Diagnostic proc ordered: rapid strep test which is positive

Exam: 24 problem points from 8 different systems

Plan: Amoxicillin, OTC Tylenol

MDM: minimal dx/mgmt , minimal data, and moderate risk

Therefore I would have an expanded problem focused HPI, detailed exam, and straightforward MDM for a 99213 correct? And if I had one more element for HPI I would have a detailed HPI which could constitute for a 99214 even with only a straightforward MDM, correct?

I really seem to struggle with MDM. Any help or advice would be greatly appreciated!

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May 11th, 2012 -

re: struggling with MDM

Still wondering if someone could help on this topic. Thanks

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May 11th, 2012 - jschmutz   323 

re: struggling with MDM

The level shouldn't exceed the MDM. If a patient came in for a hang nail and for some reason a comprehensive history and exam was done it does not justify a 99215.

The MDM for strep on a patient with no other serious health conditions does not need to exceed a 99212/99213.

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