CPT Knowledgebase - Jun 4, 2021

A patient presents to the podiatrist for a diabetic foot examination. While the diabetes is not well controlled (ie, exacerbated), the foot examination is normal. There are no data points or treatment during this encounter. May this be considered as moderate risk under the MDM risk element based on the patients diabetes? The guidelines state that [t]rained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. If the physician states that this patient is at moderate risk of developing a diabetes-related condition, would this be considered as moderate risk?

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