tci E/M Coding Alert - 2023 Issue Q4

Reader Question: Depend on Documentation to Establish Risk

Question: Do inherent risks, such as perforation, make all surgeries “high risk” in terms of medical decision making (MDM)? Kansas Subscriber Answer: Unfortunately, there isn’t a straightforward answer. Every surgical procedure carries some element of risk. However, a relatively simple procedure for an otherwise healthy adult carries a different level of risk than the level of risk for an older patient with multiple comorbidities. Furthermore, CPT® coding does not define ordinary surgical risks, (such as perforation) as high or low risk for patients. Consider this verbiage found in the E/M 2021 Errata and Technical corrections: “The...

To read the full article, sign in and subscribe to tci E/M Coding Alert.


Stay informed, get answers to your E/M coding and documentation questions, and find the help you need to bank your deserved pay with your subscription to TCI’s E/M Coding Alert.

  • Current newsletters added each month
  • Fully searchable archives - over 500 articles
  • ALL years/issues back to 2013 organized by year and issue
  • Codes mentioned in articles are linked to Code Information pages
  • Code Information pages link back to related articles
Access to this feature is available in the following products:
  • tci E/M Coding Alert +Archives

demo
request yours today
 subscribe
start today
 newsletter
free subscription

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