Wiki MDM Question

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cpclori

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For 2021 MDM I have an Acute Complicated Injury. MD ordered an L- Spine x-ray.
Does the L-Spine x-ray fall into the Low Risk of Complications category (like a CXR) ?
 
cpclori said:
For 2021 MDM I have an Acute Complicated Injury. MD ordered an L- Spine x-ray.
Does the L-Spine x-ray fall into the Low Risk of Complications category (like a CXR) ?
Click to expand...

The level of risk of potential complications of any procedure or test would need to be documented by the provider. I've never seen a provider state that a routine x-ray would carry any particular risk to a patient, so I wouldn't consider an x-ray as involving any particular risk to a patient unless the provider has specifically identified one. Normally when you're looking a risk of complications of a procedure, it's for things such as invasive procedures like endoscopies, biopsies or surgical interventions that are involved, not imaging or lab tests.
 
I have a in general question about 2021 E/M if you have a patient that is a 99203 and a prescription is written does the level automatically go to a 99204 or does all the components have to be met for a 99204???
 
cjcook17 said:
I have a in general question about 2021 E/M if you have a patient that is a 99203 and a prescription is written does the level automatically go to a 99204 or does all the components have to be met for a 99204???
Click to expand...
You have to meet 2 of 3 of the MDM components. This is widely distributed information:
  • Number and Complexity of Problems Addressed
  • Amount and/or Complexity of Data to be Reviewed and Analyzed
  • Risk of Complications and/or Morbidity or Mortality of Patient Management
 
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