May 20, 2025
Recorded April 24, 2025
Guest presenter Seth Canterbury, CPC, CPC-I
When the method for selecting the level of E/M services was changed for 2021 (office visits) and 2023 (other visits), the concept of “risk” underwent significant revision. No longer was this concept confined to just one element/subcomponent of MDM.
E/M elements for MDM There are three elements in medical decision-making and this article describes the first of three When selecting a level of service based on medical decision-making two of the three elements are required CPT® has developed definitions for many of the components in the MDM chart. The examples listed in the definitions […]
The third element of MDM: risk of complications and/or morbidity or mortality of patient management at the encounter Coding for E/M services There are three elements in medical decision-making and this article describes the third, the risk of complications and/or morbidity or mortality related to patient management When selecting a level of service based on […]
There are three elements in medical decision-making and this article describes the second, arguably, the most complex of the three elements When selecting a level of service based on medical decision-making two of the three elements are required CPT® has developed definitions for many of the components in the MDM chart. This article describes the definitions […]
Question: When using the E/M guidelines, is the problem an an acute, uncomplicated illness or an acute illness with systemic symptoms? Answer: Let’s start with the CPT definitions, from the CPT® Professional edition. Acute, uncomplicated illness Acute illness with systemic symptoms From CPT®: A recent or new short-term problem with low risk of morbidity for […]
How is risk evaluated when selecting a level of E/M service? We know that the risk from additional diagnostic testing/procedures and management is one of the three elements that determines the level of service, when MDM is used. But, how about the risk from the condition itself? This short video (I always say they’re short […]
Recorded September 28, 2023
Medical practices can prepare for audits, improve documentation and decrease compliance risk by sharpening their focus on high-risk areas, high volume services, and/or identifying confusing areas of MDM and developing and following consistent guidelines from appropriate resources. Join Pam D’Apuzzo, CPC, ACS-EM, ACS-MS, CPMA and Debra Rossi, CCS, CCS-P, CPC, CPMA of VMG Health and me for a lively and informative discussion.
Question: When auditing MDM, is there a list of drugs that are considered “drug therapy requiring intensive monitoring for toxicity?” Answer: Not from the AMA. Here’s the definition: “Drug therapy requiring intensive monitoring for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. […]
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