Results 1 to 4 of 4

MDM High Complexity ?

  1. #1
    Default MDM High Complexity ?
    Medical Coding Books

    One of the docs selected high complexity for the MDM on a new pt with a history of metastic breast disease and comes in for a surgery consult on a new adrenal mass with a high intake on a PET. He recommends total adrenalectomy, and explains the risks and benefits of the procedure to the patient- (The risk and benefits of the procedure were discussed include bleeding, transfusion of blood or blood products, infection, the need for conventional adrenalectomy, injury or regional structures including liver, vena cava and right kidney, recovery expectations, experience of the operative procedure, hazards associated with anesthesia.)

    Does this meed the high complexity? Does it meet high on the Level of Risk chart? I'd really appreciate any opinions, explanations on this.


  2. #2
    Milwaukee WI
    Default Moderate Risk
    From the brief excerpt you provide, I get moderate risk for the PROCEDURE.
    Ellective Major Surgery with no identified risk factors

    The risk factors the table is referring to are patient co-morbidities, NOT the risks of the surgery/procedure. So if the patient has DM, for example, or is on coumadin, or has a congenital heart anomaly ... those are identified risk factors.

    HOWEVER ... it is possible he is looking at the metastic breast disease with a new adrenal mass as "One or more chronic illnesses with severe exacerbation, progression or side effects of treatment." . This would fall under high risk.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Thank you F Tessa. This helps out a lot.

  4. #4
    Tessa is correct that the Table of Risk for MDM is referring to co-morbidities. Something else to consider when dealing with Oncology patients, besides chronic conditions such as DM, are the chemo drugs the patient is currently taking in treatment. When a patient who is on chemotherapy is going to have surgery we usually consider the patient high risk because of all the side effects of the chemo, such as, drug induced neutropenia, abnormal lab counts, anemia, kidney disease, etc. Something to think about!
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

Similar Threads

  1. Moderate Complexity or High Complexity MDM
    By kathymoon in forum Auditing General Discussion
    Replies: 9
    Last Post: 06-23-2014, 08:19 AM
  2. Texas work comp high complexity screen
    By jenelite in forum Anesthesia
    Replies: 1
    Last Post: 08-24-2012, 11:29 PM
  3. Need help for high complexity MDM ??
    By mcarrillo in forum E/M
    Replies: 1
    Last Post: 01-23-2012, 04:40 PM
  4. Critical Care vs. ER High Complexity
    By jaltaffer in forum Emergency Department
    Replies: 3
    Last Post: 04-27-2011, 08:33 AM
  5. Help With High Complexity
    By jifnif in forum E/M
    Replies: 1
    Last Post: 09-10-2009, 08:45 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.