For the 3rd element of E/M, risk, it is not just a risk of a procedure in general. The documentation must identify
specific risks to THAT patient for that procedure specifically. Was there any specific documentation about this in the note? If not, it is not moderate risk unless one of the other risk elements was met for moderate. Ask the auditor to show you where in the note the the risks
specific to that patient and that procedure being done on that patient are located. Some examples might be pt. has poor healing, on blood thinners, immunocompromised, skin procedure on the foot of a diabetic, etc. But, these must be documented. It can't just be the normal "blurb" that you see for every procedure about generalized risks.
As for the other parts, we would have to see the documentation. Without seeing it, if anything, you probably have a level 3 there.
For E/M leveling, in general, it does not matter if the procedure was done in the office, and it does not matter if it was scheduled or not (unless talking about some major emergent thing same day like a fracture or go to the ED, etc.). What matters is if the documentation meets the elements to report the E/M level being used or not. Further, it also matters, if using either a 25 or 57 modifier on the E/M is if the documentation also meets the requirement to report one of those modifiers. The use of the terms minor or major in the risk column don't necessarily align with the global days concept or 0-10 or 90. So you have a couple different concepts going on here. 1. the leveling of the E/M and 2. the modifiers and separate reporting of the E/M with a procedure on the same date.
Resources:
This one is talking about high but the concept is the same.
Q. Question: Do inherent risks (e.g., perforation) make all surgeries high risk to patients when selecting the level of risk for medical decision-making?
A. CPT coding does not define ordinary surgical risks (such as perforation) as high or low risk for patients. The physician or QHP who evaluates the patient is the best judge of the specific patient factors that make a procedure "high risk" for a patient. Every surgical procedure carries some element of risk; however, a relatively simple procedure for an otherwise healthy adult carries a different level of risk than the level of risk for an older patient with multiple comorbidities. Per the E/M 2021 Errata and Technical Corrections:
The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities).
As a result, the physician's documentation of his or her level-of-risk assessment based on the specific patient's risk factors is the determining component in how the MDM level of risk for the specific patient will be calculated. The MDM level has three components and level of risk is only one of three components required to determine the MDM level. The physician or QHP must also document and consider the number and complexity of the problems addressed at the encounter, as well as the amount and complexity of the data to be reviewed and analyzed. Two of the three components must be at a high level for the overall MDM level for that encounter to be considered as high. Therefore, not all surgeries will be assessed as "high risk" based simply on inherent or ordinary surgical risks.
Refer to the definitions and info about risk here:
https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
Specifically this: Surgery—Risk Factors, Patient or Procedure: Risk factors are those that are
relevant to the patient and procedure. Evidence-based risk calculators may be used, but are notre quired, in assessing patient and procedure risk.
Could be a resource if someone in your office has access:
https://www.aad.org/member/practice/coding