tci E/M Coding Alert - 2018 Issue 7

Reader Question: Know These 3 Components for Preop Clearance Success

Question: I am writing for some guidance on Medical Decision Making (MDM) E/M coding for visit where PCP provides preoperative clearance for established patient that is having surgery with a specialist. Where does this fall on the table of risk in MDM? Can you provide some examples of what would constitute a high vs. moderate or low MDM? Alabama Subscriber Answer: The table of risk is only one component of medical decision making, but the rule of thumb is that if the patient is having major surgery and there are no risk factors or a minor procedure with risk...

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