How to pick E&M Level | Medical Decision Making and Risk in Active Surveillance for Prostate Cancer

Dr. John Lin discusses coding / medical decision making in prostate cancer patients undergoing active surveillance. Active surveillance for prostate cancer during level two, three, or four EM visits depends on the specific case. Risk assessment plays a crucial role in determining the EM level. The AMA guidelines provide examples, but there are additional factors to consider. Clinicians must document their thought process and convey the nuances of the visit in their clinical documentation. Examples of different risk levels and corresponding EM levels are discussed. Clear and concise documentation, potentially aided by voice recognition technology or virtual assistants, is essential for justifying EM levels and ensuring accurate coding and billing. The Thriving Urology Practice Facebook Group:   / thrivingpractice   Dr. Lin practices at Sunrise Urology: http://www.SunriseUrology.com #Coding #EvaluationAndManagement #CPT