tci E/M Coding Alert - 2022 Issue Q2

Reader Questions: Look to Context of Conditions to Choose MDM Level

Question: A patient had labs drawn and came back in to review the results. Upon review, the practitioner diagnosed the patient with hyperlipidemia and hyperthyroidism, of which the patient has no prior history. The practitioner is going to monitor and recheck lab levels in one month. How do I categorize those problems? This scenario doesn’t seem to fall under any of the definitions in the number and complexity element column for medical decision making (MDM). AAPC Forum Participant Answer: This encounter does not neatly fit into either a low or moderate level, but probably aligns best with office/outpatient...

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