AMA CPT® Assistant - 2023 Issue 11 (November)

Questions and Answers (November 2023)

November 2023 page 22 Questions and Answers Evaluation and Management (E/M): Office and Other Outpatient Services Question: When a physician documents surgical risk factors (ie, based on the procedure-risk only, ie, benefits, risk, etc), does that constitute as high risk for the medical decision making (MDM) section? Answer: No, MDM does not automatically default to high risk based on surgical risk factors, and not all surgical procedures are high-risk. The criteria that are required for each MDM level are used with at least one other element to select an E/M code. To guide selection and to reflect the different...

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CPT® Assistant content is the official source for CPT® coding guidance. It is an instrumental tool when appealing insurance denials and validating coding to auditors. Monthly issues and an extensive archive provide comprehensive guidance on proper CPT® coding for past, present and upcoming code set releases. Archives date back to 1990 for historical use of codes, changes, rationales, coding tips and trends in the industry.

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