Forum - Questions & Answers

Apr 9th, 2016 - sdcohen4

MDM points

Does the physician have to be treated the diagnosis to get the points in the MDM points section (not the risk section)?

Apr 15th, 2016 - alincoln 2 

re: MDM points

For the Diagnosis Points section - only the conditions being managed by the provider or those affecting the patient's treatment should be counted.

I've found E/M University explains it well:
"E/M University Coding Tip: Problems which are not being addressed specifically by the physician during the encounter may still be counted if they significantly increase the complexity of the cognitive labor required. For example, consider a patient with diabetes who is being evaluated by a vascular surgeon for a lower extremity revascularization procedure. It would be appropriate for the surgeon to include diabetes as an “established problem, stable” when calculating the problem points. This is because the comorbidity of diabetes does significantly influence the risk of the procedure and the complexity of the post operative management"

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