Wiki MDM RISK DOCUMENTATION FOR MINOR PROCEDURES ORTHO/PM

[MLITE2113]

Hello!

I have multiple physicians telling me that when they recommended an injection (joint injection, ct injection, TFESI, ESI, Facet Blocks, RFAs etc) that the e/m is automatically a level 4 if they document the risks.
This is our Ortho Physician:
Here is an example of what is documented





Is this enough to count as moderate risk in MDM? For the decision to perform a minor procedure?

The only comorbidity is Obesity.
Also can the obesity be counted in the problem category in MDM based on the weight loss factor documented under counseling?
2 chronic conditions or 1? Osteoarthritis and Obesity?

This is our PM Physician

Is this enough to count as moderate in e/m mdm?

The AMA guideline update just confuses me
What do they mean by specific patient risk factors? In my mind that means they would have to document the patient is on blood thinners and discussed that the patient needs to stop blood thinners prior to the procedure - something like that....



Please help! E/M coding is so complicated!!!! Whoever codes it is AMAZING

Thanks!

 

[nraizman@gmail.com]

A joint injection is a Minor Procedure.
The medication for the injection does not currently qualify as a "prescription drug management" either, though this is something that is still controversial.
It only rises to Moderate Risk if there are specific patient risk factors. Obesity is not a patient specific risk factor.
Your surgeons are not correct and coding a Level 4 reflexively when there is an injection recommended would never survive an audit.