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MDM Risk Acute complicated Injury vs Acute UNcomplicated Injury

  1. #1
    Default MDM Risk Acute complicated Injury vs Acute UNcomplicated Injury
    Medical Coding Books
    Can someone either tell me or lead me to documentation for examples of acute complicated versus uncomplicated injuries. If a patient is seen for an injury and surgery is scheduled would that be considered complicated?

  2. #2
    Milwaukee WI
    Default Surgery
    If you are taking the patient to surgery you don't have to worry about whether the injury is complicated or or not ... with a decision for MAJOR surgery you have - at minimum - moderate risk.

    If the surgery is considered MAJOR surgery -and- there are IDENTIFIED risk factors(i.e. the physician identifies them in writing in the documentation) then you have HIGH risk.

    If the surgery is considered MAJOR surgery -and- it is being performed emergently (e.g. appendectomy), then you have HIGH risk.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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