Medicare Compliance & Reimbursement - 2021 Issue 11
Reader Questions: Use These Guidelines When Calculating Risk
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Article Overview
This reader Q&A discusses CPT office/outpatient medical decision-making guidance, with emphasis on how risk is assessed when elective major surgery is considered and the patient declines, delays, or seeks another opinion. It is aimed at coding professionals who need to understand how shared decision-making, documentation, and patient or procedure factors relate to risk level determination. The article also references AMA guidance and broader outpatient/prolonged services code changes.
Why This Topic Matters
Accurate risk interpretation is central to selecting the correct medical decision-making level in office and outpatient evaluation and management services. This article helps coders and auditors understand the documentation concepts that can influence whether a scenario supports moderate or high risk.
Article Sections
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Question
Introduces a coding question about how risk is assessed in a surgery-related scenario under current CPT medical decision-making guidance.
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Answer
Explains the general framework used to evaluate risk in the scenario and references AMA guidance relevant to outpatient and prolonged services coding changes.
What You Will Learn
- How CPT medical decision-making risk is considered when surgery is discussed but not performed
- How shared decision-making affects the assessment of possible management options
- How documentation of patient and procedure factors relates to risk evaluation
- How AMA guidance is used in the context of outpatient and prolonged services changes
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physician documentation staff
- E/M coding specialists
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