• Impression: rule out melanoma.
• Plan: Review risk, benefits, and alternative options. Schedule biopsy. Discuss unique risk factor of sebaceous peau d’orange skin more prone to contour defects after biopsy.
When determining the coding level for this scenario by MDM, 3 components must be considered: number and complexity of problems addressed at the encounter (column 1), amount and/or complexity of data to be reviewed and analyzed (column 2), and risk of complications and/or morbidity or mortality of patient management (column 3).1 There are no data that are reviewed, so the auditor will assume minimal data to be reviewed and/or analyzed (level 2, row 2 in the MDM table). However, there may be a lot of variation in how an auditor would address the number and complexity of problems (level 1). Consider that you must explicitly state what you are thinking, as an auditor may not know melanoma is a life-threatening diagnosis. From the perspective of the auditor, could this be a:
• Self-limited or minor problem (level 2, or minimal problem in the MDM table)?1
• Stable chronic illness (level 3, or low-level problem)?1
• Undiagnosed new problem with uncertain prognosis (level 4, or moderate level problem)?1
• Acute illness with systemic symptoms (level 4, or moderate level problem)?1