tci E/M Coding Alert - 2022 Issue Q3

Reader Questions: Don’t Count on a Referral to Determine MDM

Question: Our providers say that referrals are always considered low risk under the Risk of Complications and/or Morbidity or Mortality of Patient Management column of the levels of medical decision making (MDM) table. If the provider documents the conditions as worsening or new and requiring additional workup outside the scope of the practice, and therefore documents a referral to a specialist, is this a low level of MDM based on columns one and three? AAPC Forum Participant Answer: A referral can count toward MDM, but a referral itself doesn’t translate into a specific risk level on its own...

To read the full article, sign in and subscribe to tci E/M Coding Alert.

Thank you for choosing Find-A-Code, please Sign In to remove ads.