tci E/M Coding Alert - 2023 Issue Q3

Reader Questions: Brush Up on Uncertain Diagnosis Rules

Question: Does an undiagnosed new problem with uncertain diagnosis automatically translate to a moderate level of problem complexity when calculating medical decision making (MDM)? Delaware Subscriber Answer: You’re right that a condition that is undiagnosed as of the date of service (DOS) has to factor into the MDM calculation for the evaluation and management (E/M) service. For example, a stomachache could just be a little indigestion or gas, but if a provider has a suspicion that it could be something worse, the differential diagnosis needs to be documented. This shows the complexity of the encounter, which will very...

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