decisionhealth Newsletters, Part B News - 2021 Issue 4 (April)
How to set E/M risk level when a different doc does the surgery
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Article Overview
This Q&A article addresses E/M risk level selection in a scenario where one physician evaluates a patient, discusses treatment paths, and refers the patient to another surgeon for potential operative care. It is aimed at coders, billers, and clinicians who document office or telehealth evaluation and management services, with emphasis on risk assessment, problem complexity, and how referral discussions are considered in the MDM framework.
Why This Topic Matters
Correctly characterizing E/M risk affects visit level assignment and supports consistent documentation review when treatment options include procedural or surgical pathways handled by another provider.
What You Will Learn
- How E/M risk is evaluated when management options include surgery performed by another clinician
- How referral discussions fit into medical decision making documentation
- How problem severity and progression influence visit-level assessment
- How telehealth or office visit documentation may be interpreted for level selection
Who Should Read This
- Medical coders
- Clinical documentation specialists
- Billers
- Physicians and advanced practice providers
Codes Discussed
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