Do All Cataract Surgeries Mean a High Level of MDM?
Question: During a recent visit with an established patient, the ophthalmologist explained that the severity of the patient’s age-related macular degeneration made them an excellent candidate for cataract surgery. The patient talked it over with their spouse and decided to proceed with the surgery. Would this evaluation and management (E/M) visit fall under a high level of medical decision making (MDM)? Florida Subscriber Answer: Unfortunately, no. This E/M visit does not meet the criteria for a high level of MDM, which would be reported with 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.). A high level of MDM requires two of the three components to meet or surpass a high level of complexity. The patient does have a chronic illness with severe progression, but the risk of the procedure isn’t high enough to warrant the high level of MDM. According to the American Academy of Ophthalmology, a high-complexity cataract case would require “treatment in the near term, which typically means within 24 hours, or the patient will go blind or have significant vision loss today. Such a problem generally requires emergency surgery or emergency intervention.” In your case, a moderate-level E/M code, such as 99214 (… moderate level of medical decision making … 30 minutes must be met or exceeded.), would be appropriate for the visit. A risk factor for a moderate-complexity case includes decision for minor surgery. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
