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Orthopedic Coding Alert

Reader Question:

Uncertain Dx Might Factor Into MDM

Published on Wed Dec 06, 2023

Question: Does an undiagnosed new problem with uncertain diagnosis automatically translate to a moderate level of problem complexity when calculating medical decision making (MDM)? Colorado Subscriber Answer: You’re right that a condition that is undiagnosed as of the date of service (DOS) has to factor into the MDM calculation for the evaluation and management (E/M) service. For example, a headache could just [...]
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