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Question: A provider wrote that they made a diagnosis and then discussed with the patient the possibility of surgery if the condition doesn鈥檛 resolve within a certain timeframe. Does this affect leveling for medical decision making (MDM) for evaluation and management (E/M) services?

Oregon Subscriber

Answer: According to the , effective 2023: 鈥淭he risk of complications and/or morbidity or mortality of patient management. This includes decisions made at the encounter associated with diagnostic procedure(s) and treatment(s). This includes the possible management options selected and those considered but not selected after shared decision making with the patient and/or family.鈥�

However, whether the encounter meets the criteria necessary to count as risk of complications and/or morbidity or mortality of patient management depends a lot on the documentation. If the provider jots down that they mentioned surgery and discussed it as an option for a patient, it probably doesn鈥檛 count toward a higher level of MDM. However, if they include in the documentation that they discussed specifics, like risk factors that might be involved in proceeding with or foregoing surgery, then the higher level of MDM may be supported.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC