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E/m for colonoscopy

Susquehanna Valley Posted Fri 31st of October, 2014 13:49:37 PM

I have a question regarding billing for a diagnostic E/M.

On the medical decision making level of risk chart of the audit tool, I am having a difficult time under the management options selected column: my patient is having a diagnostic colonoscopy, would this be considered minor surgery with no identified risk factor, or minor surgery WITH identified risk factor.

I know this is not the only factor in deciding my office visit level, but this is the only factor that I am in question about and any assistance you give me will be greatly appreciated.

SuperCoder Answered Fri 31st of October, 2014 15:07:44 PM

Thanks for your question. In normal cases this could be considered a moderate risk (endoscopies with no identified risk factors). You could select high risk (endoscopies with identified risk factors) if the patient has some other factors that could complicate the procedure such as a bleeding risk. See the following link for additional information.

https://www.supercoder.com/coding-newsletters/my-cardiology-coding-alert/em-mdm-level-may-depend-on-proper-table-of-risk-selection-article

Hope this helps.

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