Urology Coding Alert

Pitfall: Don't miss the "if this, then that" notes when determining level of risk. When it comes to choosing the overall level of service for an evaluation and management encounter, such as an office visit, most coders will tell you that determining the medical decision making (MDM) complexity is the most complicated and difficult piece of the puzzle. If MDM is the bane of your coding existence, you aren't alone. To determine the level of MDM, you should assign points to each of the three MDM components that your urologist performs. The number of points in each category determines the final MDM level. There are three elements that contribute to the complexity of your urologist's medical decision making. "The elements are diagnoses/management options, complexity of data reviewed/ordered, and the table of risk," says Suzan Berman, CPC, CEMC, CEDC, Senior Director of Physician Services at Healthcare Revenue Assurance Associates based out [...]