Auditing:
MDM Weigh Surgical Risk to Snag the Correct E/M Level
Published on Fri Jun 04, 2010
These definitions take the mystery out of moderate vs high surgical management options.If you audit surgery in addition to family medicine, you could be losing E/M credit unless your emergency, elective, and risk factor vocab is rock solid. Under the Table of Risk's Management Options Selected column, these factors can change whether the level of risk is moderate or high, affecting the encounter's type of medical decision making and potentially changing the E/M service's level.To avoid under or over-coding the surgeon's level of risk, know the differences between: emergency major surgery (high risk) and elective major surgery. elective major surgery with no identified risk factors (moderate risk) and those with identified risk factors (high risk).Emergency Surgery Requires Immediate Performance When considering emergency surgery risk, look for the following characteristics described by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education with University of Washington Physicians.Emergency [...]