tci E/M Coding Alert - 2018 Issue 9

Reader Question: Factor More Than Risk in Pre-Op E/M Level Determination

Question: We just performed a pre-operative visit for a COPD patient of ours who is getting hernia surgery. Where does this fall on the table of risk in medical decision-making (MDM)? Can you provide some examples of what would constitute a high vs. moderate or low MDM? Texas Subscriber Answer: The table of risk is only one component of medical decision making, but the rule of thumb is that if the patient is having surgery and there are no risk factors or a minor procedure with risk factors that might make the surgery more dangerous for her, you would...

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