Moderate or High MDM – General Surgery

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The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.

This article does not apply to services performed after 1-1-2023.

Examples of Moderate MDM:

Codes: Consult, 99244,  Initial hospital 99222, Initial OBS 99219, 99235, ED 99284

• Patient presents with a breast lump. Biopsy and ultrasound planned.
• Patient with moderate exacerbation of Crohn’s disease.
• Patient with no risk factors assessed in ED, needs surgery for a hernia repair, scheduled within the next few weeks.
• 50-year-old male seen in consultation for rectal bleeding, weight loss, abdominal pain, with no chronic problems. Scheduled for colonoscopy in the near future.
• 17-year-old seen in ED, CT scan and lab work done, called to ED, patient with appendicitis, taken to surgery.