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Primary Care Coding Alert

You Be the Coder:

Can You Reckon the Referral’s Role in Determining MDM?

Published on Thu Jun 16, 2022

Question: Our providers say that referrals are always considered low risk under the Risk of Complications and/or Morbidity or Mortality of Patient Management column of the levels of medical decision making (MDM) table. If the PCP documents the conditions as worsening or new and requiring additional workup outside the scope of the practice, and therefore documents a referral to a specialist, [...]
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