My problem is that I am not the doctor, (coders in general) It is out of our area of expertise to decide what is "appropriate" as far as the extent of the exam and the things he is looking for and the rationale for same. What we have to concern ourselves with is does the documentation meet the level. Since there is so much subjectivity involved with MDM I do think it is within the physicians ability to determine the definition of minimal, limited, moderate, extensive with respect to # of dx and amount and complexity of information so long as it is applyed the same way for all patients and is documented sufficiently. So given all that if the documentations meets the requirements for a 99215 then it is that level. Just because an auditor does not feel it is life threatening is insufficient reasoning, and quite frankly out of their level of expertise to evaluate.
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