SantaRosa27
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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.