MDM and Problems Addressed

Q:

Under MDM noting that a problem is being managed by another provider does not count as the problem being managed during the visit. But what if I, the patient’s physician, note that I reviewed that provider’s recommendations with the patient to ensure they were compliant, understood the instructions and other possible treatment options?

A:

This is a great question, but tricky to answer and there certainly is room for abuse. The documentation is key.  Below is the AMA’s full definition of a problem being addressed.

Problem addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. – AMA Link

If you believe you are addressing the problem based on the above definition, then document the details well to support addressing the problem.  In order to count, the documentation must clearly prove it was evaluated/treated, including assessment, care coordination…treatment considerations.  If the documentation is not clear, the reader of the record (coder/auditor) may not count the problem, which could result in audit failure. 

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