Question Clarification on risks for minor surgery for MDM

lishakaye

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According to the MGMA quick reference sheet for 2021 E/M coding, documentation of minor surgery w/o risk factors could equal a Level 3 whereas minor surgery WITH risk factors could equal Level 4. My provider asked if these risks that need to be documented are risks of the surgery or risk factors to the specific patient. Could anyone clarify this for me? I interpreted it to mean the risk factors for the surgery they would be performing but could be wrong. I appreciate any input!

Alisha
 

lcolborn

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My take based on this statement from the AMA Grid , " Decision regarding minor surgery with identified patient ( here, you have your identified patient, and their comorbidities should they do this procedure) OR procedure risk factors ( here, you are considering the risk of the said surgery ..., what are the risk involved). And so, my answer would be either or.
 
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