Thank you! I am looking at the definitions from the AAPC on the 2023 E/M Office or Other Outpatient Audit worksheet. Under the Nature and complexity of problem(s) addressed. Acute uncomplicated illness or injury gives an example of a simple sprain. Acute, complicated injury gives the example of multiple fractures. With the associated risk portion is it low risk of morbidity? Or Moderate?Which set of guidelines are you referencing here and from what source? Just to clarify, in your post title you're saying 'moderate MDM' but in your question you're actually talking about 'moderate risk' which of course is only one of the components needed to meet moderate MDM.
Generally speaking, when specific diagnoses such as a fracture are given as example in guidelines, they're just that - examples to be used as a guide and not a fixed rule for how risk is to be classified. The risk involved in a given condition can vary from patient to patient due to its severity and potential for complications. Each case has to be evaluated on its own merits. As per the AMA's publication on E/M: "Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions."
I appreciate your response. It has helped greatly.Which set of guidelines are you referencing here and from what source? Just to clarify, in your post title you're saying 'moderate MDM' but in your question you're actually talking about 'moderate risk' which of course is only one of the components needed to meet moderate MDM.
Generally speaking, when specific diagnoses such as a fracture are given as example in guidelines, they're just that - examples to be used as a guide and not a fixed rule for how risk is to be classified. The risk involved in a given condition can vary from patient to patient due to its severity and potential for complications. Each case has to be evaluated on its own merits. As per the AMA's publication on E/M: "Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions."
OK, I see where you're finding that. But it reinforces what I said before, if you notice their wording that says 'An example may be a head injury with brief loss of consciousness, multiple fractures, multiple injuries, etc.', with the word 'may' being critical here. It's not saying you must always classify that diagnosis as having that risk.Thank you! I am looking at the definitions from the AAPC on the 2023 E/M Office or Other Outpatient Audit worksheet. Under the Nature and complexity of problem(s) addressed. Acute uncomplicated illness or injury gives an example of a simple sprain. Acute, complicated injury gives the example of multiple fractures. With the associated risk portion is it low risk of morbidity? Or Moderate?