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MDM-risk table-management option

Charlene Posted Wed 17th of June, 2020 15:28:15 PM
Hello, please advise if joint injection with steroid is considered prescription drug management (moderate risk) or minor surgery w/o risk (low risk). Although a prescription is not written or samples given, the provider is making decision as to which medication is best suited to condition and patient. The patient might have co-morbidity such as diabetes or respiratory condition that could be adversely affected by steroid. A Rx cannot be written for later self-administration by patient . The purpose for minor procedure is to treat condition with injectable medication. Is there some written guidance on this subject?
SuperCoder Answered Thu 18th of June, 2020 07:46:44 AM

Thank you for your Question!


Steroids are prescription drugs. As per the CMS Evaluation and Management Services Guide MDM table, prescription drugs fall under the moderate risk category. Documentation should Clearly describe the management of the patient, (i.e., prescription drugs, over the counter medication, surgery, etc). As per the above query, it seems the physician has not documented steroid injections in prescription or on the medical record. To count a drug as a prescription refill/administered as a moderate-level management option, the provider will need to document the reason why he has decided to continue prescribing the current medication and/or maintain the current dosage level of that medication as per the associated comorbidities. So, provided your payer follows a similar policy, refill documentation/ medication administered that is accompanied by a statement that your provider has made some kind of medication assessment will enable a prescription drug given to count as a moderate level of risk.



Hope that Helps!

Charlene Posted Thu 18th of June, 2020 14:05:55 PM
Thank you for the above information. To clarify my question, the provider is documenting his plan to either schedule a patient for epidural steroid injections or the administration of intra-articular viscosupplementation or tendon sheath injection with steroid during the encounter. The query is stemming from a insurance coder/auditor saying all the above administrations are minor surgeries which is low risk. So I'm looking for written guidance as to which risk level these scenarios are considered.
SuperCoder Answered Fri 19th of June, 2020 09:58:53 AM

Thank you for your Question!


 As per MDM table, minor surgery with no identified risk factors e.g. minor surgery with 0, XXX or 10 day global like small abscess or injection into joints considered under Low Risk.


Minor surgery with identified risk factors includes if patient have Morbid Obesity, smoking, heart disease comorbidities documented and that the increased risks were discussed with the patient proceed with surgery would be under Moderate Risk. Kindly corelate with your medical record.


As per your above stated documentation, co-morbidity such as diabetes or respiratory condition could be adversely affected by steroid, Hence, the same can be considered as identified risk factor thereby contributing towards Moderate Complexity. Please find undermentioned links for more understanding of MDM.



Hope that Helps!

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