Wiki Pre-Op Visits 2021

[irma011]

What would be the overall MDM level for a pre-op visit? We have many pre-op visits and have been told by a provider that these type of visits are by no means minimal. Majority of the time we do in house labs as well as EKG & will determine if patient is stable. If patient is stable, would this make it a level 2 visit? None of the providers ever document the risk associated with the type of surgery..

 

[kimberlywatson]

The first thing I would suggest is to ask your providers to document the risk involved as that information is necessary for you to choose the correct E/M level. Help him help you so that you can both be confident in your coding. In regards to evaluating the MDM, look at how many comorbidities or problems are being addressed as a potential risk for surgery. Ex: is this a healthy patient with no problems only there for eval because they are over 60 and need cardio clearance? Or is it a diabetic patient with COPD that may have surgical complications? I would use that information to guide you in the Problems Addressed question as well as the Risk. Don't forget about the option of coding by time as well!