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Thread: medical decision making

  1. #1

    Default medical decision making

    AAPC: Back to School
    When patient is diagnosed and given options for surgery...but no surgery is planned or scheduled what level of mdm is that? This would be a general anesthesia surgery such as a hernia. From what I have heard if surgery is "planned" or "scheduled" it would be moderate or high depending on if there are any risk factors. Or if no surgery is planned or scheduled would that be a low mdm. I still think it would be at least moderate but would greatly appreciate feedback...thank you and happy Monday!

  2. #2
    Join Date
    Apr 2007
    Baton Rouge


    From what I remember reading about this (I'm going to try to find the documentation), the code is based on the doctor's recommendations, not on what the patient chose to do about it. So in the example you stated, if the doctor recommends a minor surgery with identified risk factors, the risk level is moderate, regardless of what the patient chooses, because the same data has to be reviewed to get to this conclusion in either case. If I can find this in black-and-white, I'll post it here for you
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  3. #3


    Makes alot of sense, thank you...just did not know if there was that fine line...have a great week

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