Where does OA exacerbation with decision for knee replacement fall in the first column of 2021 MDM Table

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A patient has been followed for OA and the decision for total knee replacement is made due to exacerbation of OA and pain limiting daily activities. For the visit when the decision for surgery is made, the surgeon feels this is a high level in the 2021 "number and complexity of problems addressed" column of the medical decision making table. Although this is not a threat to life, the surgeon thinks this situation fits the description of "threat to bodily function". Do knee and hip replacements meet the intent of this definition, and if not, do you have a link to a source? Since this is a decision for major surgery and there is a discussion concerning the risks of the procedure, this would be a high level for that column under the 2021 E&M documentation guidelines. Under the 95 guidelines, this would be a low or moderate level of MDM depending on other comorbidities documented. Thank you very much.
 
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I've been told that the 'Moderate' 1 or more chronic illnesses is for when the exacerbation is mild vs the severe in the High category. So if he/she clearly documents it as severe exacerbation in the notes I would think that would support the use of the high in the 1st column. It's all going to fall back on the quality of the providers notes. Sorry I don't have a link to provide you with.
 

csperoni

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From AMA 2021 guidelines: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
Depending on the documentation, I would initially lean toward chronic illness with severe exacerbation, progression, or side effects of treatment.

Chronic illness with exacerbation, progression,or side effects of treatment: A chronic illness that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care
Chronic illness with severe exacerbation, progression,or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.
Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, or an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Examples may include acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurologic status.
 
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