opinion on MDM

Do you guys feel if a patient has a RUL mass and node involvement and they recommend surgery and the patient is going to go home and make a decision about surgery the MDM is high or moderate? I think high. But, an auditor said moderate since they didn't schedule it????

Allison K. Hiott, CCS, CPC, CPC-I
Remote Professional Coding Specialist
Reimbursement & Advisory Services Division
Greenville, SC (Eastern Standard Time Zone)

Altegra Health | The Promenade at Howard Hughes Center | 6601 Center Drive | Suite 300 | Los Angeles, CA 90045
C (864) 303-4861 |Allison.hiott@altegrahealth.com


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Comments

  • edited May 2017
    I would say moderate unless your physician documented identified risk factor(s) other than those inherent to the procedure. Not all planned surgeries equal high risk.

    Whether the surgery is scheduled or not is irrelevant in my opinion. It’s the physician’s decision making we are scoring, not the patient’s. I disagree with the auditor in that respect.

    Erica


  • Thanks. I didn’t list her risk factors but she did have them to. Thanks for the help. I agree.

    Allison K. Hiott, CCS, CPC, CPC-I
    Remote Professional Coding Specialist
    Reimbursement & Advisory Services Division
    Greenville, SC (Eastern Standard Time Zone)

    Altegra Health | The Promenade at Howard Hughes Center | 6601 Center Drive | Suite 300 | Los Angeles, CA 90045
    C (864) 303-4861 |Allison.hiott@altegrahealth.com



    AltegraHealth.com

    Strategic Analytics | Litigation Support | Coding & Reimbursement | ICD-10 Solutions | Compliance & Internal Audit | Valuation & Transactions | Revenue Cycle & IT Management

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  • This was his assessment...pretty sure this would be high

    _ year old_ recent smoker with a RUL mass with PET-positive R hilar node. Dr. _________recommends a bronchoscopy, mediastinoscopy, R VATS upper lobe wedge, possible lobectomy. Dr._____________ discussed the risks of the surgery, which include bleeding, infection, and death. All of her questions were answered, and she will consider whether she will proceed with surgery or if she will seek another opinion. She has significant medical comordities including recent ICU admission and prolonged hospitalization for intracranial hemorrhage, and additionally has radiographic evidence of emphysema, and would need to be medically optimized and cleared for surgery. She will contact the office once she makes her decision.

    Allison K. Hiott, CCS, CPC, CPC-I
    Remote Professional Coding Specialist
    Reimbursement & Advisory Services Division
    Greenville, SC (Eastern Standard Time Zone)

    Altegra Health | The Promenade at Howard Hughes Center | 6601 Center Drive | Suite 300 | Los Angeles, CA 90045
    C (864) 303-4861 |Allison.hiott@altegrahealth.com



    AltegraHealth.com

    Strategic Analytics | Litigation Support | Coding & Reimbursement | ICD-10 Solutions | Compliance & Internal Audit | Valuation & Transactions | Revenue Cycle & IT Management

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  • High risk for sure

    Beth Aldridge, CPC

    Coding Manager



    Northern California Medical Associates, Inc

    Phone: (707) 573-6145

    Fax: (707) 573-6932



  • edited May 2017
    Yes I agree the MDM is High on this one.

  • Thanks guys :-)

    Allison K. Hiott, CCS, CPC, CPC-I
    Remote Professional Coding Specialist
    Reimbursement & Advisory Services Division
    Greenville, SC (Eastern Standard Time Zone)

    Altegra Health | The Promenade at Howard Hughes Center | 6601 Center Drive | Suite 300 | Los Angeles, CA 90045
    C (864) 303-4861 |Allison.hiott@altegrahealth.com



    AltegraHealth.com

    Strategic Analytics | Litigation Support | Coding & Reimbursement | ICD-10 Solutions | Compliance & Internal Audit | Valuation & Transactions | Revenue Cycle & IT Management

    Follow Altegra Health Today:



  • I would agree with moderate: "elective major surgery with no identified
    risk factors" or "undiagnosed new problem with uncertain prognosis." Both
    are moderate decision making.

    Rhonda Johnson, CPC

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