MDM-Auditing E&M

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When determining risk (based on the Table of Risk), would the performance of a bronchscopy without the risks being indentified and the patient not having any respiratory co-morbidities, be classified as moderate risk? "Diagnostic endoscopic with no identified risk."

Does the risk have to be listed in order to classified as high or can the risks be "implied"?
 
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Identified Risk Factors

To qualify as High risk on the MDM table of risk, IDENTIFIED risk factors must be clearly and specifically stated by the provider. They can not be implied.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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Thanks

Thanks for responding. I felt the same way. However, Dr. had been trained in past that "implied" risk justify a high risk.
 
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