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
Alisha