Visit has a detailed history and expanded pf exam, and I am thinking a Moderate MDM for a 99214.
My questions are regarding the three elements of MDM.
This is the Impression and Plan Summary:
PAIN IN RIGHT ARM – New.
Orders: US: extremity – right – non vascular.
BICEPS TENDON RUPTURE – New. Ultrasound reveals bicep tendon tear Ortho referral made. May use ibuprofen 800mg PO TID otc prn pain. Medication education provided including possible side effects.
Here are my questions:
1) would the pain in right arm dx count as a moderate level in the table of risk as an Undiagnosed new problem with uncertain prognosis? (Also my boss had mentioned that 2 new problems equal Moderate Risk but I can’t find documentation for that)
2) Does the provider get 2 data points? One point for ordering the US for the pain in arm, and one point for reviewing the US for the bicep tendon tear?
I would appreciate any input regarding this to further my knowledge and understanding regarding MDM and this type of scenario.
TIA
KM