Wanting a higher office E/M level, a coder asks the provider, “Can we say high complexity MDM?” What is the compliance assessment of that query?
Select an answer to reveal the explanation.
Short Explanation
“Can we say high complexity?” is a nudge wearing a question mark. Leading queries that hand the provider the level you want are noncompliant. Ask about the clinical work and decisions—not the code shopping list.
Full Explanation
Ethical query practice prohibits leading questions that introduce or imply a preferred code, diagnosis, or E/M level. Suggesting “high complexity MDM” steers documentation toward a reimbursement outcome rather than clarifying clinical facts. Appropriate clarification focuses on clinical indicators and decision-making elements already present or needing explanation, without naming the desired billed level as the goal.