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I am a cardiologist from Connecticut. I thought you may be able to shed some light on my coding dilemma.

I have a question on scoring problem points on MDM as a consultant

If I am a consultant and a PMD sends me a new pt for chest pain which I determine requires NO further work up ( say because stress test ordered by PMD which I review is really negative but someone else thought it was positive) and the patient also has htn and Dm .

Within the MDM components of data, problems and risk ,

Is the max problem points I get in this case 4 or 3?

My coder was saying that I can only get 3 points because htn and Dm are technically new to me and there is a max of 3 points for a new problem with no further work-up with a maximum count of one new problem with no further work up . I said that htn and dm has to count despite the fact that they are not "established " to me and therefore garner 2 more point ( 1 for htn and 1 for dm) for a total of 5 - but since max is 4- I just get 4 qualifying for high complexity.

With this case I did a comprehensive history , comprehensive exam and On MDM
Had 4 data points ; graded it as moderate risk( 2 or more stable problems) ; and I thought (more than 4 problem points (chest pain-3; htn-1; dm-1) I coded it as 99245

My coder said I only got 3 points on the problem category since he would not count the dm and htn for some reason and downgraded it to a 99244.

I have tried to research this online but there is absolutely nothing to explain how a consultant counts problem points on a new patient consult (99245) when the reason for the consult does not require further work up. Do the related co-morbidities garner extra problem points if they are addressed as well just like in a 99215 follow up? I was not aware that there was a difference in counting problems between a new consult and a follow up to the consult?

If a consultant uses the 99205/4 for Medicare Pts - do the rules change, is there a max 3 points for new problem with no further work up no matter how many problems are addressed?

Thank u very much

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Reply with quote  #2 
I would say that since you are seeing the patient primarily for chest pain, that would be the new problem with no work-up for you , worth 3 points. The DM & HTN would be considered comorbidities, contributing towards the Risk, unless these issues were treated or addressed as individual problems on the visit. The documentation would have to support this fact.
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