Wiki decision for surgery

[brittanyhelmer]

When choose an E/M code if the patient presents to the emergency room for gallstones or appendicitis... and they decide to do surgery in the same day... where do you think this will fall with an MDM? moderate or high?

I would choose moderate if this was laparoscopic and the pt was in for a pre op visit, but would you consider this high if the decision was in the ED?

 

[csperoni]

MDM is based on 2 of 3 elements -
1) Number of diagnoses or management options
2) Amount and/or complexity of data to be reviewed
3) Risk of complications and/or morbidity or mortality
The information you provided is not sufficient to code this. For example, ordering/reviewing testing, co-morbidities, etc all play a role, not the location of the patient.
That being said, typically an acute illness being treated with urgent major surgery usually falls in high risk, but without knowing elements 1 & 2, you cannot say it is high MDM.