MAR 05, 2021
Moderate Decision Making for Medically Necessary Surgery
Question: When any surgery is determined to be medically necessary, such as cataract surgery or entropion, but the patient defers surgery, are we still able to meet moderate medical decision-making?
Answer:
Yes. Moderate MDM is met when the problem is exacerbated or worsening, plus a decision for a major surgery was made qualifying for 99204 and 99214.
See the Conquering New E/M Documentation Guidelines for Ophthalmology for additional information.