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complexity medical decision making

SuperCoder Posted Fri 21st of May, 2010 16:54:36 PM

Hi Camille,

We are working on this, will get back to you soon.


SuperCoder Answered Mon 24th of May, 2010 07:04:38 AM

Determination of "level" of E/M code (consult / OPD) depends upon the "key components", ie, History, examination and medical decision making. These criterias must meet or exceed the stated requirements to qualify for a particular level of E/M service. The E/M documentation plays an important role here. To be able to code a service as "High" level of E/M, the MDM should be of high complexity, for which there should be extensive number of Dx or disease management options, extensive amount of data to be reviewed, high risk of complications, morbidity / mortality involved. In my opinion, this particular case cannot be coded to the "high level", as Dx is direct & limited (fem. neck Fx) and Sx is not to be done in a very urgent manner ("..waiting to be medically stable" ).
Kindly check your documentation ans consult the CPT manual (E/M section guidelines) to confirm the level of service.

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