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Selecting the correct code for many evaluation and management (E/M) services starts with determining whether a patient is new or established, as defined by CPT® guidelines.
The post Navigate the New vs. Established Patient Decision Tree appeared first on AAPC Knowledge Center.
Guidelines and auditing tools help with the decision-making process involved in coding E/M services. Selecting evaluation and management (E/M) service levels in the emergency department (ED) can be a challenge, and the medical decision making (MDM) component is particularly difficult to score. E/M service guidelines are defined separately in the CPT® code book, by the […]
The post Evaluate Medical Decision Making in the Emergency Department appeared first on AAPC Knowledge Center.
An ultrasound was done and the patient has a 5 cm mass near her ovary. The MD is planning surgery to remove the mass, it is not known for certain whether or not the mass is benign or malignant. The MD believes that the mass is an identified risk factor because the mass is potentially cancerous. We believe that at this point, the surgery should not be given credit for high risk surgery with identified risk factors because the mass is not identified as being cancerous at this point.
I could consider this being a risk factor if the provider makes the case for it in the note, but just a mass with the potential of being malignant we do not believe to be an inherent identified risk factor.
Thoughts???? Thank you!
1) My Physicians are wondering what type of tool they should be using. Do you have any recommendations?
2) How do we document this? Is it something you cover in an office visit and put your discussion in the office note?
3) Do we have to scan something specific in the patients chart?
Thank you!
Carol Hodge, CPC, CDEO, CCC, CEMC
The patient was seen on 8/1 and the decision was made to proceed with a partial mastectomy. Consent forms were signed and surgery was scheduled for the end of the month. The patient was seen again on 8/10 because she had questions about the procedure and recovery time. Since the decision for surgery had been made at the 8/1 visit, the 8/10 visit was not charged. (8/10 visit is being considered global since the decision for surgery was already made and the visit was related to the surgery)
The patient has decided to postpone the surgery and it has not been rescheduled. (she’s seeking another opinion) In this case, does the visit on 8/10 now become billable? Or should it be left as a global visit since a surgical plan was in place when the patient was seen on 8/10?
Haven’t had this come up before now, and I’m interested to see how everyone else handles it.
Thanks 
Under the new Medicare Decision, should the physician also have a shared decision making encounter before placing a left ventricular lead (CPT 33225) for CRT therapy/bi-ventricular pacing?
Thanks in advance for your help.