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General Surgery Coding Alert

Reader Question:

Let Provider Dictate Risk

Published on Wed Dec 20, 2023

Question: How do we know the “risk” involved in an encounter so we can understand the level of medical decision making (MDM)? Kentucky Subscriber Answer: The physician or other qualified healthcare professional documenting an encounter should state the level of risk. CPT® does not provide any clear definition of risk level. Consider this verbiage found in the E/M 2021 Errata and Technical [...]
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