tci Medicare Compliance & Reimbursement - 2010 Issue 21

Auditing: Weigh Surgical Risk to Select Correct E/M Level

These definitions take the mystery out of moderate vs high surgical management options. You could be losing E/M credit on your surgery cases unless your emergency, elective, and risk factor vocab is rock solid. Under the Table of Risk's Management Options Selected column, these factors can change whether the level of risk is moderate or high, affecting the encounter's type of medical decision making and potentially changing the E/M service's level.To avoid under or over-coding the surgeon's level of risk,know the differences between: emergency major surgery (high risk) and elective major surgery. elective major surgery with no...

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