tci E/M Coding Alert - 2024 Issue Q2

Leveling: Consider This Leveling Advice for MDM

Evaluate all available information when determining risk. Assessing murky situations to define medical decision making (MDM) levels can seem daunting for rookie coders and even seasoned veterans. But this step in finding the correct evaluation and management (E/M) doesn’t have to be a headache. Know That a Patient May Refuse a Test Scenario 1: The physician orders a spirometry, but the patient refuses to undergo the test. You’re trying to determine the encounter’s complexity level, which leads you to wondering whether the physician should still get credit for the order. What you should know: Physicians frequently...

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