tci General Surgery Coding Alert - 2024 Issue Q1

Reader Question: Let Provider Dictate Risk

Question: How do we know the “risk” involved in an encounter so we can understand the level of medical decision making (MDM)? Kentucky Subscriber Answer: The physician or other qualified healthcare professional documenting an encounter should state the level of risk. CPT® does not provide any clear definition of risk level. Consider this verbiage found in the E/M 2021 Errata and Technical corrections: “The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a...

To read the full article, sign in and subscribe to tci General Surgery Coding Alert.

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