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.
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