CPT Knowledgebase - Jun 30, 2023

Under “Number and Complexity of Problems Addressed at the Encounter” in the “Levels of Medical Decision Making (MDM), there is an option of “Acute, uncomplicated illness or injury” for low level of MDM, however in the moderate level of MDM it is only “Acute, complicated injury”. Is there a reason that illness is not included in this moderate category? We have cases where a complicated illness would be appropriate, especially in the Emergency Department setting and are questioning whether this was intentionally left off.

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