Outpatient Facility Coding Alert - 2018 Issue 7
Reader Question: Know These 3 Components for Preop Clearance Success
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Article Overview
This article addresses a coding question about preoperative clearance for an established patient and explains the general framework used to assess medical decision making in E/M coding. It is useful for coders, auditors, and clinicians who document preoperative evaluations and want to understand the broad factors that influence visit level selection. The discussion focuses on the three MDM components, common clearance scenarios, and the relationship between documented complexity and office/outpatient E/M level selection.
Why This Topic Matters
Preoperative clearance encounters are common and can be difficult to level correctly because risk is only one part of medical decision making. Understanding how the three MDM components interact helps support more consistent E/M documentation review and visit selection.
What You Will Learn
- How preoperative clearance encounters fit into E/M medical decision making
- The three components that contribute to MDM complexity
- How general clearance scenarios affect overall visit level selection
- Why documentation of the MDM components matters for established patient office visits
Who Should Read This
- Medical coders
- E/M auditors
- Physicians
- Clinical documentation staff
- Practice managers
Codes Discussed
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