The physician evaluates a patient for knee pain and sends him for an x-ray. Based on the x-ray results, it is determined that the patient has arthritis in the knee and is to receive an injection into the knee for the pain. The physician feels the visit warrants moderate decision making (MDM) because the medication used in the knee injection procedure could be considered as meeting the risk category of MDM. Is that correct? ...
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Article Overview
This premium coding Q&A addresses how an evaluation for knee pain, imaging follow-up, and a knee injection are viewed when considering office/outpatient E/M medical decision making. It is aimed at coders, billers, auditors, and clinicians who need to understand the general distinction between medication administration during a procedure and prescription drug management in the risk element of MDM. The article discusses the type of guidance used to assess whether a visit meets a moderate level of complexity, without providing a full coding workflow.
Why This Topic Matters
Accurately distinguishing medication administration from prescription drug management can affect E/M leveling and the relationship between procedure reporting and office visit reporting.
What You Will Learn
- How office visit E/M medical decision making is discussed in the setting of knee pain and follow-up imaging
- How medication administration during a procedure is generally distinguished from prescription drug management
- What broad factors are considered when evaluating the risk component of MDM
- How a joint injection can relate to reporting alongside an E/M service at a high level
Who Should Read This
- Medical coders
- Medical billers
- Coding auditors
- Physicians
- Qualified healthcare professionals
- Practice managers
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