tci E/M Coding Alert - 2021 Issue Q4

Reader Questions: Use These Guidelines When Calculating Risk

Question: In the current CPT®Elements of Medical Decision Making (MDM) table, one of the examples of moderate risk of complications is “decision regarding elective major surgery without identified patient or procedure risk factors.” What does this mean, and how does it differ from the high risk of complications example where the patient or procedure risk factors are identified? For example, a patient is diagnosed with stenosis and radiculopathy. After some imaging and some conservative treatment, the doctor recommends surgery as the next step and explains this to the patient. The patient then decides against surgery or...

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