Wiki MDM Obtain fluid from oral cavity

medcode12

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Looking for some clarification in MDM. Under diagnostic procedure ordered would a throat or nose swab be considered "obtaining fluid from an oral cavity?"

Thank you for any input.
 
This would not qualify as a diagnostic procedure in the risk section - per the CMS documentation guidelines, they are referring to the risk associated with 'surgical or invasive' procedures that are ordered:

"The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.... If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure e.g., laparoscopy, should be documented.

However, if the provider is obtaining this specimen to be tested, or sent out for testing, it would count for one data point in the MDM.
 
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