Wiki MDM Question

[cpclori]

For 2021 MDM I have an Acute Complicated Injury. MD ordered an L- Spine x-ray.
Does the L-Spine x-ray fall into the Low Risk of Complications category (like a CXR) ?

 

[thomas7331]

For 2021 MDM I have an Acute Complicated Injury. MD ordered an L- Spine x-ray.
Does the L-Spine x-ray fall into the Low Risk of Complications category (like a CXR) ?

The level of risk of potential complications of any procedure or test would need to be documented by the provider. I've never seen a provider state that a routine x-ray would carry any particular risk to a patient, so I wouldn't consider an x-ray as involving any particular risk to a patient unless the provider has specifically identified one. Normally when you're looking a risk of complications of a procedure, it's for things such as invasive procedures like endoscopies, biopsies or surgical interventions that are involved, not imaging or lab tests.

 

[cjcook17]

I have a in general question about 2021 E/M if you have a patient that is a 99203 and a prescription is written does the level automatically go to a 99204 or does all the components have to be met for a 99204???

 

[csperoni]

I have a in general question about 2021 E/M if you have a patient that is a 99203 and a prescription is written does the level automatically go to a 99204 or does all the components have to be met for a 99204???

You have to meet 2 of 3 of the MDM components. This is widely distributed information:

• Number and Complexity of Problems Addressed
• Amount and/or Complexity of Data to be Reviewed and Analyzed
• Risk of Complications and/or Morbidity or Mortality of Patient Management

https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf