EM Question re MDM

[CCO-support]

A student from another program emailed this question in:

IMPRESSION: Right recurrent gynecomastia.
PLAN: The patient had a right breast ultrasound on November 17, and it showed a hypoechoic area measuring 1.7 x 0.7 x 1.2 cm in the 11 o’clock position of the right breast. There was no Doppler flow, and the transmission suggested that this was a cystic lesion. Follow-up in a month was suggested at that time. Because of this ultrasound and because this is symptomatic, I have recommended a simple mastectomy under general anesthesia. The patient is in agreement. I filled out the prison forms requesting permission, and I described the operation to the patient.

What is the level of Medical Decision Making? Answer
a. Straightforward
b. Low
c. Moderate
d. High

in the textbook they were mentioning something about give 2 points for new dx and give 4 pts for a worsening dx so I try to look at the table for MDM and I just dont know min limited multiple extensive is what range of numbers are they going by, same for the next category under amt of complex data there are no ranges of numbers to go by so please try to explain how to work with this table. thanks

 

[suzanberman]

In my opinion, if you take the note apart, this is what you'd have:
Established problem, worsening or not improving.....2 points
Data review...................................................................1 point
Risk...............................................................................moderate

That said, the MDM would be LOW. I assumed this was an established patient based on the "follow up" comment. If the patient was NEW, then the problem would be a new problem with no additional work-up and worth 3 points. That would then bump the MDM to a MODERATE.

I do hope that helps.

Suzan Berman BS, CPC, CEMC, CEDC